From the Guidelines
The recommended treatment for stage 5 lupus nephritis involves immunosuppressive therapy, with initial treatment consisting of corticosteroids such as prednisone at 0.3–0.5 mg/kg/day, combined with either mycophenolate mofetil (MMF) at 2–3 g/day or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), as recommended by the 2019 EULAR/ERA-EDTA guidelines 1.
Key Considerations
- The target of therapy is complete response (proteinuria <0.5–0.7 g/24 hours with (near-) normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria 1.
- Hydroxychloroquine is recommended with regular ophthalmological monitoring 1.
- Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids 1.
- The choice of agent depends on the initial regimen and plans for pregnancy 1.
Treatment Approach
- Initial treatment usually consists of corticosteroids such as prednisone, combined with either MMF or low-dose intravenous CY 1.
- This induction phase generally lasts 3-6 months, followed by a maintenance phase using lower doses of prednisone plus either MMF or azathioprine for at least 3 years.
- Calcineurin inhibitors like tacrolimus or cyclosporine may be added for resistant cases, as suggested by the 2012 American College of Rheumatology guidelines 1.
Supportive Care
- Supportive care is also essential, including blood pressure control with ACE inhibitors or ARBs targeting <130/80 mmHg, antiproteinuric measures, and addressing cardiovascular risk factors.
- Assessment for kidney and extra-renal disease activity, and management of comorbidities is recommended 1.
From the Research
Treatment Options for Stage 5 Lupus Nephritis
The treatment for stage 5 lupus nephritis typically involves immunosuppressive therapy to reduce inflammation and prevent further kidney damage. Some of the recommended treatment options include:
- Low-dose cyclophosphamide and corticosteroids for induction therapy 2
- Mycophenolate mofetil as an alternative treatment for induction therapy 2, 3
- Azathioprine or mycophenolate mofetil for maintenance therapy 2, 4
- Rituximab for patients with refractory lupus nephritis 2
Immunomodulatory Therapies
Immunomodulatory therapies, such as biologic agents, have shown promise in treating lupus nephritis. These therapies target specific pathways that contribute to the inflammatory response, aiming to reduce tissue damage while preserving immunocompetence. Some of the immunomodulatory therapies that have been studied include:
- Abetimus sodium
- Rituximab
- Epratuzumab
- Abatacept
- Belimumab
- Tocilizumab
- Infliximab 5
Apheresis Therapy
Apheresis therapy, which involves the removal of pathogenetically relevant autoantibodies, has been studied as a potential treatment for lupus nephritis. However, the current evidence suggests that plasma exchange offers no clear benefit over standard immunosuppression in patients with active lupus nephritis 6. Adsorption procedures, which allow for the selective removal of immunoglobulins, may be a more promising approach, but further studies are needed to determine their effectiveness 6.