Lupus Nephritis–Specific Management Guidelines Issued

Hahn BH, McMahon MA, Wilkinson A et al, American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken). (2012) 64(6):797-808

New guidelines for the screening and treatment of patients with lupus nephritis have been issued by the American College of Rheumatology (ACR). The guidelines, which are specific to lupus nephritis, address methods for identifying renal disease, the use of newer therapies, and treatment of pregnant patients who have systemic lupus erythematosus (SLE) with kidney involvement. Until now, there had been only general SLE guidelines for clinicians.

Up to 322,000 adult Americans have a diagnosis of SLE, according to ACR estimate. Evidence of nephritis is seen in an estimated 35% of adults in the United States at the time of SLE diagnosis, and kidney involvement develops in up to 60% of patients during the first 10 years with the disease. When lupus nephritis is present, the rate of patient survival is reduced to 88% at 10 years, and the survival rate is even lower for African Americans, according to previous studies.

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To establish the 2012 lupus nephritis guidelines, investigators reviewed medical literature from 1966 through 2010 for all evidence pertaining to "lupus kidney disease." Three panels of researchers helped review the data and produce the following recommendations:

• Renal biopsy (for previously untreated patients who have active nephritis).
• Adjunctive treatment (use of background therapy with hydroxychloroquine, use of angiotensin-converting enzyme inhibitors, and control of blood pressure [goal of 130/80 mm Hg or lower for almost all patients who have SLE with nephritis]).
• Induction of improvement in patients with International Society of Nephrology Class III/IV lupus glomerulonephritis, Class IV or IV/V plus cellular crescents, or Class V "pure membranous" lupus nephritis.
• Maintaining improvement in patients responsive to induction therapy (with azathioprine or mycophenolate mofetil).
• Changing therapies in patients who are not adequately responsive to induction therapy.
• Identifying vascular disease in patients with SLE who have renal abnormalities.
• Managing nephritis in pregnant patients.

The authors noted that the guidelines are limited by the absence of agreed-on terms for remission, flare, and response and limited data to inform recommendations for corticosteroid dosing and tapering of immunosuppressive therapies and suggested that ongoing evaluation and expansion of the guidelines are needed to further improve outcomes for patients who have SLE and nephritis.