Blog entry by Meguid El Nahas

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by Meguid El Nahas - Wednesday, 9 May 2012, 3:47 AM
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The American College of Rheumatology (ACR) has issued the first-ever guidelines for the screening, treatment, and management of lupus nephritis (LN). 
The guidelines are published in the June issue of Arthritis Care & Research
They were initially presented at ACR 2011.

Clinical conclusions
1- the 2012 guidelines are a significant advance because they address total therapy of LN, not just short-term treatment.

2- At this time, more than half of patients with systemic lupus erythematosus develop LN within 10 years and up to 30% of those cases progress to end-stage renal disease within 15 years of diagnosis.

3- The ACR panel, which developed the guidelines, recommends renal biopsy for all patients with clinical evidence of active, previously untreated LN. 

4- They do not recommend immunosuppressive treatment for patients with class 1 (minimal mesangial immune deposits on immunofluorescence with normal light microscopy) or class 2 (mesangial hypercellularity or matrix expansion on light microscopy with immune deposits confined to mesangium) renal damage. However, they do recommend aggressive treatment for patients with class 3 or higher renal pathology.

5- Mycophenolate and cyclophosphamide plus glucocorticoids are the mainstay of treatments for induction of improvement in [LN] of serious histologic classes (except if patient is pregnant), and azathioprine [AZA] and mycophenolate are both acceptable for maintenance of improvement (except in pregnancy). Recommending pulse steroids in treatment of class 3 and 4 active proliferative disease. Rituximab or calcineurin inhibitors should be considered if standard treatments fail."

6- An algorithm for management of pregnant woman with active [LN] is included in the guidelines.The guidelines note that women should be off MMF or CYC for at least 6 weeks prior to conception.

7- Renal failure may not come quite as quickly in pure membraneous nephritis, but the long-term prognosis is not great."

8- Studies have shown that MMF is more effective than CYC in African-American woman, and this is highlighted in these guidelines."

9- Consensus on the use of calcineurin inhibitors: The agents have potential renal toxicity, but have been shown to be effective in membranous lupus during the short term.

10- The role of rituximab in LN also remains somewhat uncertain. Rituximab is listed as a relatively late intervention.

11- Recommendation to perform renal biopsies whenever the therapeutic decisions would be altered by knowing 1) histologic classification and 2) level of activity and of chronicity on the biopsy.

12- There needs to be more use of remission-inducing agents at proper doses for proper duration, transition from induction to maintenance therapies without a gap if possible, prevention of adverse effects when possible.

13- The guidelines do not address the questions of how long to treat during maintenance therapy and when begin to taper MMF because there are few data on the topic.

14- With regard to the increasing incidence of end-stage renal disease associated with LN, there are fibrotic processes plus other reasons such as hypertension that contribute to atherosclerosis. Many patients progress to renal failure not due to active nephritis, but due to the combined effects of irreversible damage accrued over many years.

Arthritis Care Res. 2012;64:797-808.
[ Modified: Thursday, 1 January 1970, 1:00 AM ]