From the Guidelines
Patients with lupus nephritis flares should be admitted to the hospital when they present with severe manifestations that require immediate intervention and close monitoring, such as acute kidney injury, nephrotic-range proteinuria, uncontrolled hypertension, or signs of other severe organ involvement. These severe manifestations include acute kidney injury with rapidly declining renal function, nephrotic-range proteinuria (>3.5g/day) with complications like severe edema or hypoalbuminemia, uncontrolled hypertension, electrolyte abnormalities (particularly hyperkalemia), pulmonary edema from fluid overload, or signs of other severe organ involvement such as neurological symptoms or severe thrombocytopenia 1. Initial management typically involves high-dose intravenous methylprednisolone (500-1000mg daily for 3 days), followed by oral prednisone (1mg/kg/day, maximum 60mg) and consideration of immunosuppressive therapy such as cyclophosphamide (0.5-1g/m² monthly) or mycophenolate mofetil (target dose 2-3g/day) 1. Supportive care including fluid management, antihypertensives, and diuretics is essential. Hospital admission allows for prompt initiation of aggressive immunosuppression, close monitoring of renal function and electrolytes, management of complications, and coordination of care between rheumatology and nephrology. The goal is to rapidly control inflammation and prevent permanent kidney damage, as delays in treatment can lead to irreversible nephron loss and progression to end-stage renal disease. According to the KDIGO 2024 clinical practice guideline for the management of lupus nephritis, patients who show unsatisfactory response to initial therapy should be managed with an algorithmic approach that includes verifying adherence to treatment, ensuring adequate dosing of immunosuppressive medications, and considering switching to an alternative recommended treatment regimen or adding rituximab or other biologic therapies 1. It is also important to note that the management of lupus nephritis should be individualized and based on the specific needs and circumstances of each patient, taking into account factors such as disease severity, comorbidities, and potential side effects of treatment 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Hospital Admission for Lupus Nephritis Flare
A patient with Lupus (Systemic Lupus Erythematosus) nephritis may require hospital admission during a flare when there is a significant increase in disease activity. The following indicators may necessitate hospital admission:
- Increase in proteinuria and/or serum creatinine concentration 2
- Abnormal urine sediment 2
- Reduction in creatinine clearance rate as a result of active disease 2
- Severe hematuria, declining renal function, or refractory nephrotic syndrome 3
- Systemic flares, such as those requiring more than 2 weeks of oral steroids 4
Treatment and Management
Hospital admission may be required to manage and treat the flare, which may involve:
- Aggressive immunosuppressive therapy, such as intravenous cyclophosphicide or mycophenolate mofetil 5
- Low-density lipoprotein apheresis (LDL-A) for refractory lupus nephritis 3
- A low steroid and mycophenolate mofetil regimen, which may result in better long-term safety and reduced toxicity 6
- Monitoring for early detection and treatment of renal flares to improve outcomes 2
Renal Flare Indicators
Renal flares can be indicated by: