How do you manage nephropathy associated with TB or lupus?

From the Guidelines

Management of nephropathy associated with lupus requires a targeted approach, with the most recent guideline recommending initial therapy with glucocorticoids plus mycophenolic acid analogs, low-dose intravenous cyclophosphamide, belimumab with either mycophenolic acid analogs or low-dose intravenous cyclophosphamide, or mycophenolic acid analogs and a calcineurin inhibitor for active Class III or IV lupus nephritis 1. For lupus nephritis, the treatment strategy is guided by the class of nephritis determined by kidney biopsy.

• Class III or IV lupus nephritis typically requires induction therapy with high-dose corticosteroids combined with either cyclophosphamide or mycophenolate mofetil, followed by maintenance therapy with lower-dose steroids and either mycophenolate mofetil or azathioprine.
• The choice of agent depends on the initial regimen, plans for pregnancy, and the presence of adverse prognostic factors, with mycophenolate mofetil and calcineurin inhibitors being alternatives for patients with nephrotic-range proteinuria 1.
• Supportive care includes blood pressure control targeting <130/80 mmHg using ACE inhibitors or ARBs, which also reduce proteinuria, and regular monitoring of kidney function, proteinuria, and drug toxicity is essential 1. Key considerations in the management of lupus nephritis include:
• The target of therapy is complete response, defined as 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, and the assessment for kidney and extra-renal disease activity, and management of comorbidities is recommended 1.
• Early nephrology consultation is recommended for optimal management, as treatment may need adjustment based on disease severity, kidney function, and patient response 1. The goal is to treat the underlying inflammatory process while preventing progression to end-stage kidney disease, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

To induce a diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus The management of nephropathy associated with TB or lupus may involve the use of prednisone to induce a diuresis or remission of proteinuria in the nephrotic syndrome.

• Key points:
  • Prednisone is indicated for the treatment of nephrotic syndrome, including cases due to lupus erythematosus.
  • The use of prednisone in TB-associated nephropathy is not explicitly mentioned in the provided drug labels.
  • It is essential to consult the relevant medical literature and clinical guidelines for the most up-to-date and comprehensive information on managing nephropathy associated with TB or lupus 2.

From the Research

Management of Nephropathy

• Nephropathy associated with TB or lupus can be managed using various treatments, although the provided studies focus on lupus nephropathy.
• The use of mycophenolate mofetil (MMF) has been studied in patients with lupus nephropathy, showing promising results in reducing proteinuria 3, 4.
• A study published in 2005 found that MMF reduced 24-hour urinary protein excretion from a median of 2.26 g to 0.66 g at follow-up (P = 0.0039) 3.
• Another study published in 2017 found that 52% of patients reached 0.50 grams of proteinuria within 51 days of starting MMF, and 77% reached 0.50 grams or less within 260 days 4.

Angiotensin Inhibition or Blockade

• Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) has been shown to reduce proteinuria and improve renal function in patients with quiescent lupus nephritis and persistent proteinuria 5.
• A retrospective study found that ACEI/ARB treatment reduced proteinuria and improved serum albumin in 14 patients with persistent proteinuria despite quiescent lupus nephritis 5.

Other Treatment Options

• Tacrolimus has been studied as a treatment option for membranous or quiescent lupus nephritis with proteinuria resistant to angiotensin inhibition or blockade 6.
• A pilot study found that tacrolimus reduced proteinuria and increased serum albumin in six patients with membranous/inactive lupus nephritis and persistent proteinuria despite angiotensin inhibition/blockade 6.
• However, one patient developed biopsy-proven chronic nephrotoxicity after 10 months of tacrolimus treatment, highlighting the potential risk of subclinical nephrotoxicity 6.

Transformation of Lupus Nephritis

• The transformation of lupus nephritis from one histologic pattern to another is well described, and a case report found that a patient developed membranous lupus nephritis while receiving MMF 7.