Narrative ReviewTen Common Mistakes in the Management of Lupus Nephritis
Section snippets
Assuming that intravenous cyclophosphamide is the gold-standard induction agent for lupus nephritis
Following the initial publication by Austin et al9 in 1986, intravenous (IV) cyclophosphamide has been considered the gold standard for treatment of lupus nephritis. Based on this study, the National Institutes of Health (NIH) has promoted high-dose cyclophosphamide as a first-line induction agent for lupus nephritis, and this regimen is used by many rheumatologists and nephrologists. The cyclophosphamide dosage is 0.5-1.0 g/m2 monthly for 6 months, followed by repeat dosing every 3 months for 1
Improper dosing of corticosteroids
The National Kidney Foundation’s KDIGO (Kidney Disease: Improving Global Outcomes) and other guidelines (American College of Rheumatology and the European League Against Rheumatism/European Dialysis and Transplantation Association) recommend an initial prednisone dosage of 1 mg/kg, with a slow taper over 6-12 months.20 The guidelines also recommend using low-dose prednisone (≤10 mg/d) for maintenance therapy, and for relapse, the same dose of prednisone that was effective in inducing original
Not using antimalarial agents routinely
Antimalarial agents such as hydroxychloroquine have been used to treat mucocutaneous, musculoskeletal, serosal, and constitutional manifestations of SLE. In randomized controlled trials and post hoc analyses, hydroxychloroquine has been shown to reduce the risk of damage accrual,21 improve survival,22, 23 and decrease the frequency of lupus flare.24, 25 It also has been shown to improve kidney outcomes. There is an increased probability of remission in patients with membranous nephritis treated
Using urinary sediment for response criteria
The panel convened by the American College of Rheumatology to examine outcome markers in lupus nephritis recommends using urinary sediment for assessing response.31 According to the committee, improvement was defined as changing from active urinary sediment to inactive urinary sediment (eg, ≤5 red blood cells, ≤5 white blood cells, and no red blood cell or white blood cell casts). They defined worsening as active sediment in a patient who previously had inactive urinary sediment and for
Not scaling the intensity of immunosuppression to the different classes of lupus nephritis, especially class V membranous lupus
Membranous lupus nephritis (MLN) accounts for approximately 10%-20% of cases of lupus nephritis.33 Although the risk of decrease in kidney function is not as great as that with the endocapillary proliferative variants, up to 20% of patients with MLN require dialysis or kidney transplantation within 10 years of diagnosis.34, 35, 36 Kidney survival is only 50% in patients with MLN at 20 years,36 but a recent study demonstrated kidney survival > 80% at 15 years.37 Furthermore, there is a sizable
Missing nonadherence to therapy as a cause of treatment failure
A common concern in the medical field is whether patients adhere to the regimen of care recommended by the physician and the extent of their persistence over time. According to research, the highest estimate is that 50% of individuals with chronic disease comply with the recommendations of their physicians, irrespective of disease, treatment, or age.43 Adherence and persistence are low, even for patients who have diseases that carry a high or moderate risk of death.44, 45, 46
Similarly, in SLE,
Not reducing or minimizing immunosuppressive exposure in patients with advanced kidney disease
In a patient with stage 4 or 5 CKD secondary to lupus nephritis, a renal-limited flare might not warrant another course of aggressive immunosuppressive therapy. There will be significant scarring in the kidney and the patient will have very little or no benefit from another course of aggressive therapy. The intensity of immunotherapy should be guided by extrarenal manifestations.
For patients who are on dialysis therapy, the immunosuppressive dose should be minimized, if possible, because they
Forgetting to monitor side effects of immunosuppression and to use prophylaxis
All the immunosuppressants used in managing lupus nephritis have side effects that need close monitoring and use of appropriate prophylaxis. Unfortunately, some of this recommended monitoring gets overlooked and patients end up with significant preventable health care problems.
The following are the commonly missed side effects.
Performing a biopsy on the kidney, especially in a high-risk patient, when it will not affect therapy
Diagnosis of lupus nephritis based on only clinical features is not very reliable, emphasizing the need for kidney biopsy. Histopathologic findings in lupus nephritis can be very diverse and kidney biopsy not only determines the diagnosis and prognosis, but guides the management. Kidney biopsy also helps rule out other kidney disease that may affect patients of similar age and sex. These include renal thrombotic microangiopathy, acute tubular necrosis, drug-induced interstitial nephritis, focal
Neglecting to address pregnancy
Approximately 90% of patients with lupus are women. When given the diagnosis of lupus, many are concerned about becoming pregnant. Advising these patients about pregnancy and managing them during pregnancy can be challenging. It is important to involve a high-risk obstetrician and a rheumatologist who have experience in managing pregnant patients with lupus.
Many patients with active lupus have no idea that pregnancy at this time is fraught with risk for both mother and fetus. It is incumbent
Acknowledgements
Support: None.
Financial Disclosure: Dr Silverman is a consultant for Eli Lilly and Glaxo Smith Kline. The remaining authors declare that they have no relevant financial interests.
References (63)
- et al.
Morbidity of systemic lupus erythematosus: role of race and socioeconomic status
Am J Med
(1991) - et al.
The outcome of lupus nephritis in Jamaican patients
Am J Med Sci
(2007) - et al.
Long-term follow-up of patients with lupus nephritis. A study based on the classification of the World Health Organization
Am J Med
(1987) - et al.
Membranous nephropathy in systemic lupus erythematosus: long-term outcome and prognostic factors of 103 patients
Semin Arthritis Rheum
(2012) - et al.
Mycophenolate mofetil and intravenous cyclophosphamide are similar as induction therapy for class V lupus nephritis
Kidney Int
(2010) - et al.
Risk factors for peritonitis in long-term peritoneal dialysis: the Network 9 peritonitis and catheter survival studies. Academic Subcommittee of the Steering Committee of the Network 9 Peritonitis and Catheter Survival Studies
Am J Kidney Dis
(1996) - et al.
Persistent lupus activity in end-stage renal disease
Am J Kidney Dis
(1999) - et al.
End-stage renal disease and systemic lupus erythematosus
Am J Med
(1996) Ophthalmologic considerations and testing in patients receiving long-term antimalarial therapy
Am J Med
(1983)- et al.
Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology
Ophthalmology
(2002)