genitourinary disorders
Lupus Nephritis
Treatment of Lupus Nephritis
Angiotensin inhibition for hypertension or proteinuria Corticosteroids plus eithermycophenolatemofetil orcyclophosphamidefor active, potentially reversible nephritis Kidney Transplantation for patients with receptor blocker (ARB) is indicated for patients with even mild Hypertension (eg, blood pressure [BP] Treatment is guided by the histologic classification of the lupus nephritis, the degree of disease activity and chronicity, and the presence of concomitant kidney disorders. Activity is estimated by the activity score as well as clinical criteria (eg, urine sediment, increasing urine protein, increasing serum creatinine). Many experts believe that a mild to moderate chronicity score, because it suggests reversibility, should provoke more aggressive therapy than a more severe chronicity score. Nephritis with the potential for deterioration and for reversibility is usually class III or IV; it is unclear whether class V nephritis warrants aggressive treatment. Theactivity scoredescribes the degree of inflammation. The score is based on cellular proliferation, fibrinoid necrosis, cellular crescents, hyaline thrombi, wire loop lesions, glomerular leukocyte infiltration, and interstitial mononuclear cell infiltration. The activity score is less well correlated with disease progression and is used, rather, to help identify active nephritis. Thechronicity indexdescribes the degree of scarring. It is based on presence of glomerular sclerosis, fibrous crescents, tubular atrophy, and interstitial fibrosis. The chronicity index predicts progression of lupus nephritis to renal failure. A mild to moderate chronicity score suggests at least partially reversible disease, whereas more severe chronicity scores may indicate irreversible disease. Treatment for proliferative lupus nephritis combines corticosteroids with other immunosuppressants ( Treatment references ). ( Treatment references ). Reasonable alternatives for induction therapy include After an appropriate renal response has been achieved with induction therapy, immunosuppressive therapy is continued for at least 2 years and often longer. Whencyclophosphamideis used as initial therapy, patients are switched tomycophenolateformaintenancetherapyto limit toxicity fromcyclophosphamide.Mycophenolateis also preferred overazathioprinefor maintenance therapy because of higher rates of relapse observed withazathioprineuse. However,azathioprineis preferred for patients who want to become pregnant.Azathioprineis also a reasonable option for patients who are intolerant tomycophenolateor have limited access due to cost. Low-doseprednisone(eg, 0.05 to 0.2 mg/kg orally once a day) is continued in most patients and titrated based on disease activity. , there is a lack of consensus regarding the role of immunosuppressive therapy, and some experts limit its use depending on the degree of proteinuria and findings on Renal biopsy . However, patients who have concurrent lupus membranous nephropathy and focal or diffuse lupus nephritis are treated using the same approach as for focal or diffuse lupus nephritis alone. Anticoagulation is of theoretical benefit for patients with antiphospholipid syndrome nephropathy, but the value of such treatment has not been established. However, patients with Antiphospholipid Syndrome (APS) (APS) and a definite thrombotic event should be anticoagulated in accordance with preferred agents for APS. Kidney Transplantation is an option for patients with end-stage kidney disease due to lupus nephritis. Recurrent disease in the graft is uncommon (< 5%), but risk may be increased in Black people, females, and younger patients. 1.Fanouriakis A, Kostopoulou M, Cheema K, et al: 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis.Ann Rheum Dis9(6):713-723, 2020. doi: 10.1136/annrheumdis-2020-216924 2.Rovin BH, Caster DJ, Cattran DC, et al: Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.Kidney Int95(2):281-295, 2019. doi: 10.1016/j.kint.2018.11.008 3.Tunnicliffe DJ, Palmer SC, Henderson L, et al:Cochrane Database Syst Rev;6(6):CD002922, 2018. doi: 10.1002/14651858.CD002922.pub4 4.Rovin BH, Onno Teng YK, Ginzler EM, et al: Efficacy and safety ofvoclosporinversus placebo for lupus nephritis (AURORA 1): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial.Lancet397(10289):2070-2080, 2021. doi: 10.1016/S0140-6736(21)00578-X 5.Rovin BH, Furie R, Onno Teng YK, et al: A secondary analysis of theBelimumabInternational Study in Lupus Nephritis trial examined effects ofbelimumabon kidney outcomes and preservation of kidney function in patients with lupus nephritis.Kidney Int101(2):403-413, 2022. doi: 10.1016/j.kint.2021.08.027 