Treatment in Lupus Nephritis

Adjunctive Therapy

• all SLE patients with nephritis be treated with a background of hydroxychloroquine (lower flare rates and lower renal damage)

• All lupus nephritis patients with proteinuria ≥ 0.5 g per 24 hours should have blockade of the renin-angiotensin system, with ACEi or ARBs (reduces proteinuria approximately 30%, and significantly delays doubling of serum creatinine and progression to end stage )

• Management of blood pressure and cholesterol (higher risk of atherosclerosis)

Treatment based on Classifications

• Corticosteroid therapy should be instituted if the patient has clinically significant renal disease. 
• Use immunosuppressive agents, particularly cyclophosphamide, azathioprine, or mycophenolate mofetil, if the patient has aggressive proliferative renal lesions, as they improve the renal outcome

Class I-II

• requires no specific therapy
• may require treatment if proteinuria is greater than 1000 mg/day. Consider prednisone in low-to-moderate doses (ie, 20-40 mg/day) for 1-3 months, with subsequent taper

Class III-IV

• Mycophenolate mofetil was found to be superior to azathioprine in maintaining control and preventing relapses of lupus nephritis in patients who have responded to induction therapy

Class V:

Treatment at ESRD

• Patients with ESRD require dialysis and are good candidates for kidney transplantation
• Patients with end-stage renal disease (ESRD), sclerosis, and a high chronicity index based on renal biopsy findings are unlikely to respond to aggressive therapy. In these cases, focus therapy on extrarenal manifestations of systemic lupus erythematosus (SLE)

References:

1. http://emedicine.medscape.com/article/330369-treatment#aw2aab6b6b1aa

2. American College of Rheumatology Guidelines for Screening, Case Definition, Treatment and Management of Lupus Nephritis