Contemporary lupus nephritis treatment

The Lupus 2025 congress brought together world SLE thought leaders.

Outcomes in lupus nephritis are akin to the glass half full. Serial monotherapy is out, as the percentage who achieved a complete renal response was very low and some went to end stage kidney disease (ESKD).

So we are better and RCTs in active LN show higher complete and partial renal responses but we have a ceiling effect where MOST are not in sustained complete renal response.

Solutions:

  1. Early identification & Rx of LN – screen your pts with chemical urinalysis, microalbuminuria, esp in early disease and ongoing
  2. Low threshold to get a renal bx and also when appropriate repeat bx
  3. Keep doing research for liquid biomarkers (urine, serum)
  4. All LN Class IV, V needs triple Rx
    1. MMF (or occ Cyclo) + Pred + advanced Rx (Belimumab, CNI, Obinutuzimab)
    2. Steroids and rapidly taper, limit overall dose
  5. Use HCQ, optimize vit D
  6. Just as important in my opinion: Rx of all renal protective/comorbidities
    HTN aim like T2 DM target
    Proteinuria ACI, SGLT2i
    Fluid balance
    Lipids aim like T2 DM target
    Lytes
    Glucose intolerance
    Ideal weight
    Check and improve adherence
  7. Good dialogue with nephrologist and assign who dose what Rx and who sees when
  8. Involve patient for improving ADHERENCE (the unspoken reason for many Rx failures/recurrences)
  9. Continue to monitor other SLE organs
  10. Improve mental health, encourage exercise, get info (free) from internet to help the pts on their complex journey
  11. Consider if/when immune suppressive Rx can be tapered and withdrawn
  12. Avoid pregnancy in active LN, on teratogenic drugs

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