The American College of Rheumatology issues guidelines for management of lupus nephritis

May 3, 2012

The American College of Rheumatology (ACR) has issued newly created guidelines for the screening, treatment, and management of lupus nephritis—a severe manifestation of systemic lupus erythematosus (SLE) where the disease attacks the kidneys. Previously, only general guidelines for SLE existed for clinicians. The guidelines, available today in Arthritis Care & Research, are specific to lupus nephritis and include methods for identifying renal disease, newer therapies, and treatment of pregnant SLE patients with kidney involvement.

The ACR estimates that up to 322,000 adult Americans are diagnosed with SLE, a chronic autoimmune disease that causes inflammation, fatigue, joint pain, and organ damage. Lupus nephritis is one of the most serious complications of SLE where inflammation of the kidney could lead to renal failure. Medical evidence suggests that 35% of adults in the U.S. have evidence of nephritis at the time of SLE diagnosis, and up to 60% develop kidney involvement during the first 10 years with the disease.

Furthermore, previous studies report that patient survival is reduced to 88% at 10 years when lupus nephritis is present, and that survival rate is even lower for African Americans. "Lupus nephritis can be life-threatening, and proper management of the disease is vital to prevent permanent organ damage and preserve quality of life for patients," explains one of the lead guideline contributors, Dr. Bevra Hahn, Professor of Medicine at the University of California, Los Angeles (UCLA). "Given the serious threat of kidney involvement in SLE and the availability of newer therapies, it was necessary to create specific guidelines for managing the care of patients with lupus nephritis."

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 were involved with reviewing the data and producing the recommendations that include:

  • Advising renal biopsy (in previously untreated patients with active nephritis)
  • Adjunctive treatment (background therapy with hydroxychloroquine, ACE inhibitors, control of blood pressure to goal of 130/80 or lower for almost all SLE patients with nephritis)
  • Induction of improvement in patients
    • with ISN Class III/IV lupus glomerulonephritis
    • with Class IV or IV/V plus cellular crescents
    • with Class V "pure membranous"

  • Maintaining improvement in patients responsive to induction therapy (with azathioprine or mycophenolate mofetil)
  • Changing therapies in patients not adequately responsive to induction therapy
  • Identifying vascular disease in SLE patients with renal abnormalities
  • Treating nephritis in pregnant patients

Despite the availability of new therapeutics, studies have shown an increase in the incidence of end-stage renal disease from over the past twenty years, with specific increases in young patients, African Americans, and in the southern U.S. "We look forward to seeing a reduction in these trends with implementation of these guidelines as part of high-quality, comprehensive care for SLE patients," said Dr. Hahn.

The authors acknowledge that the guidelines are limited by the absence of agreed terms for remission, flare and response, and limited data to inform recommendations for steroid dosing and tapering of immunosuppressive therapies. Dr. Hahn concludes, "Ongoing evaluation and expansion of the is necessary to further improve outcomes for patients with SLE and nephritis."

More information: doi:10.1002/acr.21664

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