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Discontinuation of immunosuppression in proliferative lupus nephritis: is it possible?

The search for an optimal therapy for proliferative lupus nephritis (LN) is still ongoing [1,2]. Maintenance treatment most often consists of low-dose prednisone, generally combined with either azathioprine, hydroxychloroquine or mycophenolate mofetil. Since the prognosis of proliferative LN has improved considerably and the morbidity of therapy is substantial, the aim of treatment has changed from preventing mortality to diminishing morbidity. Because of the cumulative side effects of long-term immunosuppression, there is a constant effort to keep drug therapy at a minimum and, wherever possible, to discontinue it altogether. Compared with other manifestations of systemic lupus erythematosus however, physicians may be more reluctant to discontinue therapy in patients with LN, especially since each flare is considered a risk factor for a worse renal outcome. So far, no randomized controlled studies have been carried out in which maintenance treatment after reaching remission was withdrawn prospectively.