Who should a patient with lupus nephritis be referred to?

Referral for Lupus Nephritis

Patients with lupus nephritis must be comanaged by both nephrologists and rheumatologists with expertise in lupus, as the multidisciplinary nature of this disease—involving kidney injury in the context of systemic autoimmune disease—mandates collaborative specialist care. 1

Primary Specialist Referrals

Nephrology Referral

• All patients with suspected or confirmed lupus nephritis require nephrology consultation for kidney-specific management, including decisions about renal biopsy, interpretation of histological findings, and management of kidney-specific complications 1
• Nephrologists guide decisions regarding immunosuppressive therapy dosing adjustments based on kidney function (particularly when eGFR ≤45 ml/min per 1.73 m²) 1
• They manage renoprotective strategies including RAAS blockade, SGLT2 inhibitors, blood pressure optimization, and monitoring for CKD progression 1

Rheumatology Referral

• Rheumatologists are essential for managing systemic lupus erythematosus activity and extrarenal manifestations that commonly accompany lupus nephritis 1
• They coordinate immunosuppressive therapy selection and monitor for systemic disease flares 1, 2
• Rheumatologists ensure appropriate use of hydroxychloroquine (≤5 mg/kg/day), which should be given to all lupus nephritis patients unless contraindicated 1, 2

Specialized Referrals Based on Clinical Context

Nephropathology

• A nephropathologist with expertise in lupus nephritis should evaluate all kidney biopsies to ensure accurate ISN/RPS classification (Classes I-VI), as this directly determines treatment intensity 1, 3
• Proper tissue processing for light microscopy, immunofluorescence, and electron microscopy requires specialized pathology expertise 3

Pediatric Specialists (for childhood-onset disease)

• Children with lupus nephritis require comanagement by pediatric nephrologists and pediatric rheumatologists with specific lupus expertise 1
• Additional support from clinical psychologists, psychiatrists, or social workers is often beneficial given adherence concerns, growth issues, fertility preservation needs, and psychosocial impacts on school and peer relationships 1

Hematology (for thrombotic complications)

• Patients with lupus nephritis and thrombotic microangiopathy should be comanaged with an experienced hematologist when appropriate expertise is available 1
• This is particularly critical when TTP is suspected (PLASMIC score indicating intermediate-to-high risk) or when antiphospholipid syndrome is present 1

Transplant Nephrology (for advanced disease)

• Patients progressing to kidney failure require transplant nephrology referral, as kidney transplantation is preferred over long-term dialysis and should be pursued once disease is quiescent 1
• Transplant evaluation can begin while on dialysis, with shorter dialysis duration associated with better post-transplant outcomes 1

Timing and Setting of Care

Center-Based Management

• Management or periodic evaluation in centers with lupus nephritis expertise is strongly recommended given the complexity of disease monitoring, treatment decisions, and comorbidity management 1
• This is particularly important for patients with severe Class III/IV disease (NIH activity index >5, chronicity index >2, proteinuria >3 g/24h, or creatinine increase >20%) 4

Ongoing Collaborative Care

• Regular communication between nephrologists and rheumatologists is essential for monitoring disease activity through proteinuria, serum creatinine, eGFR, complement levels (C3/C4), and anti-dsDNA antibodies 2
• Visits should occur every 2-4 weeks during the first 2-4 months after diagnosis or flare, then adjusted based on treatment response 2

Common Pitfalls to Avoid

• Do not delay specialist referral while awaiting biopsy results—both nephrology and rheumatology should be involved from the point of clinical suspicion 1, 3
• Avoid single-specialty management—even with stable disease, both specialties provide complementary expertise that improves long-term outcomes 1
• Do not overlook the need for nephropathology expertise—community pathologists without lupus nephritis experience may misclassify disease, leading to inappropriate treatment 1, 3