At what level of impaired renal function should dialysis be considered in patients with lupus nephritis?

When to Initiate Dialysis in Lupus Nephritis

Dialysis in lupus nephritis should be initiated using standard end-stage kidney disease (ESKD) criteria—not based on a specific GFR threshold—and all methods of kidney replacement therapy (hemodialysis, peritoneal dialysis, or transplantation) can be safely used in SLE patients. 1

Standard Dialysis Indications Apply

The decision to initiate dialysis in lupus nephritis follows the same clinical criteria used for any cause of kidney failure, rather than lupus-specific thresholds:

• Uremic symptoms (encephalopathy, pericarditis, bleeding diathesis)
• Severe metabolic acidosis refractory to medical management
• Hyperkalemia unresponsive to conservative measures
• Volume overload causing pulmonary edema despite diuretics
• Severe electrolyte disturbances threatening life 1

The EULAR/ERA-EDTA guidelines explicitly state that all methods of kidney replacement treatment can be used in patients with SLE, without preferential restriction based on the underlying lupus diagnosis. 1

GFR Thresholds Are Not Absolute Dialysis Triggers

While advanced chronic kidney disease stages are important for monitoring, specific GFR cutoffs do not mandate dialysis initiation:

• **GFR <30 mL/min/1.73 m²** (CKD stage 3b-4) requires close monitoring but not automatic dialysis, as kidney biopsy decisions at this level should be based on kidney size >9 cm and evidence of active disease (proteinuria, active urinary sediment). 1

• GFR 15-29 mL/min/1.73 m² (CKD stage 4) represents advanced disease, but research demonstrates that 62% of lupus nephritis patients with advanced CKD (stages 3b-4) did not progress to ESRD over 10 years of follow-up when appropriately managed. 2

• GFR <15 mL/min/1.73 m² (CKD stage 5/ESKD) typically requires renal replacement therapy, though the exact timing depends on clinical symptoms rather than the number alone. 1

Predictors of Progression to ESKD

Understanding which patients are at highest risk helps anticipate dialysis needs:

High-risk features predicting ESKD include:

• Baseline eGFR ≤33 mL/min/1.73 m² (HR 3.5) 3
• Fibrous crescents on biopsy (HR 3.4) 3
• No response to treatment at 6 months (HR 17.1) 3
• Class IV proliferative lupus nephritis 4
• Baseline hypertension 3, 4
• Higher baseline creatinine (>1.2 mg/dL) 4
• Active serology (high anti-dsDNA, low C3/C4) at time of advanced CKD diagnosis 2

Protective factors that may delay or prevent ESKD:

• Treatment with renin-angiotensin system (RAS) blockers 2
• Achieving partial or complete response by 6 months 3
• Class V membranous lupus nephritis (significantly lower ESRD risk) 4

Management During Advanced CKD to Delay Dialysis

Aggressive immunosuppression should continue even with poor renal function (eGFR 15-59 mL/min/1.73 m²), as treatment response at 6 months strongly predicts long-term outcomes. 3

Key management strategies include:

• Continue immunosuppression guided by extrarenal manifestations once on dialysis 1
• Optimize blood pressure control with RAS blockade when feasible 2
• Monitor for treatment response at 3 months (evidence of proteinuria improvement) and 6 months (≥50% proteinuria reduction) 1
• Avoid premature treatment switches in patients with nephrotic-range proteinuria at baseline, who may require an additional 6-12 months to achieve complete response 1

Transplantation Considerations

Transplantation should be preferred over chronic dialysis when feasible, with specific timing requirements:

• Extrarenal lupus should be clinically and ideally serologically inactive for at least 6 months before transplantation 1
• Superior outcomes are achieved with living donor and pre-emptive transplantation (before dialysis initiation) 1
• Antiphospholipid antibodies should be measured during transplant preparation due to increased vascular thrombosis risk in the transplanted kidney 1

Common Pitfalls to Avoid

• Do not delay immunosuppressive treatment based solely on low GFR if there is evidence of active disease (proteinuria, active sediment, normal kidney size) 1
• Do not assume dialysis is inevitable in advanced CKD—many patients stabilize with appropriate management 2
• Do not use GFR alone to determine dialysis timing; clinical symptoms and complications should guide the decision 1
• Be aware of increased infection risk in patients on peritoneal dialysis who remain on immunosuppressive agents 1
• Monitor for vascular access thrombosis in patients with antiphospholipid antibodies 1