Treatment of lupus nephritis in adult patients

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Algorithms

Treatment of lupus nephritis in adult patients

Sundeep Upadhyaya

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India

Abstract guidelines and Rheumatology practitioners all over the world

This set ofmanagement principles which is based on personal

practice and refers to the American College of Rheumatology

Guidelines1 and the European league against Rheumatology

recommendations2 are particularly suited to India and the

Indian Ethnic population. It also takes into account the pre-

vailing principles of treatment widely accepted among the

rheumatologists of the Indian subcontinent.

The ISN/RPS classification of lupus nephritis (2003)3 defines

nephritis in the clinical setting of a patient with SLE, who has

proteinuria >500 mg per day or 3þ proteinuria by dipsticks

and/or active urinary sediment. This classification broadly

lists classes of lupus nephritis from Class I to Class VI. This

algorithm outlines the treatment plan for Class III/IV and

Class V lupus nephritis. Some notable points e Cyclo-

phosphamide (CYC) in the Indian Subcontinent is usually

initiated at a dose of 750 mg/m,2 and final doses are adjusted

to a nadir of leucocyte counts at (2 weeks e 3000e4000/mL)

follow up. The “EUROLUPUS” regime (500 mg CYC every

fortnight � 3 months) for induction treatment is valid mostly

for certain white European ethnic groups. Not mentioned in

this algorithm are I.V. boluses of Methyl Prednisolone com-

monly used in India and the world over for induction (based

on expert opinion only).

Class I/II lupus nephritis needs no specific treatment and

for Class VI nephritis, renal replacement therapy is the pre-

ferred mode of treatment all over the world including India.

One exception would be Class II nephritis with >1 g/day pro-

teinuria, where according to the EULAR/ERA-EDTA recom-

mendations2 Steroids and AZA may be used. Both the ACR

E-mail address: sundeepupadhyaya@hotmail.com.0976-0016/$ e see front matterhttp://dx.doi.org/10.1016/j.apme.2013.01.010

recommend treatment of all their SLE patients with hydrox-

ychloroquine and treat hypertension to a target of �130/80;

use ACE inhibitors/ARBs for any proteinuria >500 mg per day;

and statins to treat LDL cholesterol >100 mg per day. As for

MMF (Mycophenolate Mofetil) doses, the Asian/Indian popu-

lation canmake dowith 2 g per day for induction instead of 3 g

per day, except when there are significantly more crescents

seen on histopathology and there is significant activity (as

deemed by the histopathologist).

For younger female patients, where MMF cannot be used

(severe disease, extensive crescents on histopathology or

have failed MMF therapy) cyclophosphamide therapy can be

and is very frequently used along with luprolide to prevent

gonadal toxicity. As for pregnant patients, in my personal

practice (and also as spelled out in the ACR lupus guidelines),

the services of an obstetricianegynaecologist, who has

experience with treatment of lupus patients should be

employed. Adjunctive therapy like Calcium, Vitamin D sup-

plements, & Iron and folic acid therapy are also mandatory.

The following is the accepted norm for pregnant lupus

nephritis patients: (a) no activity on histopathology, no spe-

cific therapy; (b) for minimal mild activity, hydroxy-

chloroquine 200e400 mg per day and (c) for significant

nephritis, glucocorticoids (GC) (þ), Azathioprine (AZA). Some

other notable highlights of my personal practice are the def-

initions of “improved/not improved” in the algorithm (these

are loosely based on the work of several Indian investigators

and the ACR guidelines). Also of note, is the omission of

Azathioprine for induction; it is now the second agent of

choice after MMF for maintenance therapy1,2 (usually 3 years).

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r e f e r e n c e s

1. Hahn BH, McMahon MA, Wilkinson A, et al. AmericanCollege of Rheumatology guidelines for screening,treatment and management of lupus nephritis.2012;64:797e808.

2. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint EuropeanLeague Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult andpaediatric lupusnephritis.AnnRheumDis. 2012;71(11):1771e1782.

3. Weening JJ, D’Agati VD, Schwartz MM, et al. The classificationof glomerulonephritis in systemic lupus erythematosusrevisited. J Am Soc Nephrol. 2004;15:241e250.

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