Management of Lupus Nephritis in Patients Undergoing Dialysis
For patients with lupus nephritis requiring dialysis, hydroxychloroquine should be continued indefinitely with appropriate dose adjustments for renal function, while immunosuppressive therapy should be individualized based on extrarenal disease activity and potential for renal recovery. 1
Key Management Principles
Immunosuppressive Therapy
- Continue hydroxychloroquine (6.5 mg/kg/day or 400 mg/day, whichever is lower) with dose adjustment for patients with GFR <30 ml/min, as it is associated with higher rates of renal response, fewer renal relapses, and reduced accrual of renal damage 1
- Assess potential for renal recovery, as 10-28% of patients with lupus nephritis who develop renal failure requiring dialysis may recover enough function to discontinue dialysis 2
- Monitor disease activity closely, as clinical activity of SLE is often quiescent in most patients with end-stage lupus nephritis on dialysis 2
- Consider continuing immunosuppressive therapy for at least 3-6 months after initiating dialysis to evaluate potential for renal recovery 2, 3
Medication Considerations
- For patients with active extrarenal lupus manifestations, continue immunosuppressive therapy with appropriate dose adjustments for renal function 1
- Consider mycophenolic acid (MPA) with dose reduction (1-2 g/day) for maintenance therapy in dialysis patients with monitoring of drug levels, as recommended for patients with GFR <30 ml/min 1
- Belimumab may be considered as add-on therapy for patients with active disease on dialysis, as it has shown improvement in renal parameters and decreased disease activity in small studies 4
- Adjust glucocorticoid doses based on extrarenal disease activity, with efforts to minimize exposure due to increased risk of complications in dialysis patients 1
Monitoring and Follow-up
- Regular monitoring of SLE disease activity including anti-dsDNA antibody levels and complement (C3/C4) levels every 3 months 1
- Monitor for infections vigilantly, as they are the most common cause of death in the first 3 months of dialysis in lupus patients 2
- Evaluate cardiovascular risk factors and implement appropriate management strategies as recommended for non-lupus chronic kidney disease patients 1
- Annual ophthalmological screening for patients on hydroxychloroquine, starting after 5 years of treatment or sooner if there are risk factors for retinal damage 1
Renal Transplantation Considerations
- Wait at least 3 months on dialysis before proceeding with kidney transplantation 2
- Recurrence of lupus nephritis in the allograft is rare, and graft survival rates are comparable to non-lupus patients 2
- Continue hydroxychloroquine post-transplantation to reduce risk of disease flares 1
Special Considerations
Management of Complications
- Treat complications of chronic renal insufficiency (anemia, cardiovascular disease, metabolic bone disease) as in patients without SLE 1
- Provide appropriate immunizations with non-live vaccines according to EULAR recommendations 1
- Monitor and manage cardiovascular risk factors aggressively, as cardiovascular complications are a common cause of death in lupus nephritis patients on long-term dialysis 2
Emerging Therapies
- Novel therapies including voclosporin and obinutuzumab are under investigation for lupus nephritis but have not been specifically studied in dialysis patients 5
- For patients not responding to conventional therapy before reaching end-stage renal disease, consider rituximab as an alternative option based on uncontrolled studies 1