From the Guidelines
The recommended treatment approach for Systemic Lupus Erythematosus (SLE) patients with Chronic Kidney Disease (CKD) involves a combination of immunosuppressive therapy and supportive care tailored to disease severity, with the goal of achieving complete response by 12 months, as outlined in the 2020 EULAR/ERA-EDTA recommendations 1. The treatment approach should include induction therapy with either mycophenolate mofetil (2-3g daily) or low-dose intravenous cyclophosphamide (500 mg × 6 biweekly doses), combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) 1.
- Key considerations in the treatment approach include:
- The use of hydroxychloroquine, which is recommended for all patients with SLE, unless contraindicated, at a dose not exceeding 5 mg/kg/real BW 1
- The importance of regular ophthalmological monitoring for patients on hydroxychloroquine 1
- The need for blood pressure control targeting <130/80 mmHg using ACE inhibitors or ARBs to reduce proteinuria and slow CKD progression
- Regular monitoring of kidney function, proteinuria, and lupus activity, with treatment adjustments based on response
- Maintenance therapy should include mycophenolate mofetil or azathioprine, with no or low-dose glucocorticoids (<7.5 mg/day) 1. This approach aims to preserve kidney function by controlling inflammation while minimizing medication side effects, as SLE-related kidney damage significantly impacts long-term prognosis and quality of life.
From the Research
Treatment Approach for SLE Patients with CKD
The treatment approach for Systemic Lupus Erythematosus (SLE) patients with Chronic Kidney Disease (CKD) involves the use of immunosuppressive agents to manage lupus nephritis.
- The goal of treatment is to induce remission, prevent renal flares, and slow the progression of CKD.
- Several studies have compared the efficacy of different immunosuppressive agents, including mycophenolate mofetil (MMF), cyclophosphamide (CYC), and azathioprine (AZA) 2, 3, 4, 5, 6.
Immunosuppressive Agents
- MMF has been shown to be effective in inducing remission and preventing renal flares in patients with lupus nephritis, with a lower risk of toxicity compared to CYC 3, 4, 5.
- CYC is a traditional treatment for lupus nephritis, but it is associated with significant toxicity, including infection and gonadal toxicity 3, 4, 6.
- AZA is another immunosuppressive agent that has been used to maintain remission in patients with lupus nephritis, with a lower risk of toxicity compared to CYC 3.
Treatment Regimens
- A study published in 2005 found that sequential regimens of short-term CYC induction followed by MMF or AZA maintenance were efficacious and safe for the treatment of proliferative lupus nephritis 3.
- Another study published in 2014 found that induction therapy with short-term high-dose intravenous CYC followed by MMF was effective in preventing renal relapses, end-stage renal disease, and mortality in patients with proliferative lupus nephritis 5.
- A study published in 2018 compared the efficacy of MMF, low-dose CYC, and high-dose CYC in patients with lupus nephritis, and found that MMF was associated with a higher rate of overall remission at 6 months 6.
Considerations
- The choice of treatment regimen should be individualized based on the patient's disease severity, renal function, and other factors 2, 3, 4, 5, 6.
- Patients with SLE and CKD require close monitoring of their renal function, blood pressure, and urine protein levels to adjust their treatment regimen as needed 2, 3, 4, 5, 6.