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Review
. 2023 Mar 22;16(9):1384-1402.
doi: 10.1093/ckj/sfad055. eCollection 2023 Sep.

Diagnosis and treatment of lupus nephritis: a summary of the Consensus Document of the Spanish Group for the Study of Glomerular Diseases (GLOSEN)

Jorge E Rojas-Rivera  1   2 , Clara García-Carro  3 , Ana I Ávila  4 , Mar Espino  5 , Mario Espinosa  6 , Gema Fernández-Juárez  7 , Xavier Fulladosa  8 , Marian Goicoechea  9 , Manuel Macía  10 , Enrique Morales  5   11   12 , Luis F Quintana  13   14 , Manuel Praga  11   12
Affiliations
Review

Diagnosis and treatment of lupus nephritis: a summary of the Consensus Document of the Spanish Group for the Study of Glomerular Diseases (GLOSEN)

Jorge E Rojas-Rivera et al. Clin Kidney J. .

Abstract

Lupus nephritis (LN) is the most frequent serious manifestation of patients with systemic lupus erythematosus (SLE). Up to 60% of SLE patients develop LN, which has a significant impact on their quality of life and prognosis. Recent advances have improved the diagnostic approach to LN, and new drugs that block specific pathways and kidney damage progression have been developed. Several randomized and well-powered clinical trials have confirmed the efficacy of these agents in terms of proteinuria remission and preservation of kidney function in the medium and long term, with an acceptable safety profile and good tolerance. The combination of different therapies allows for reduction of the dose and duration of corticosteroids and other potentially toxic therapies and leads to an increase in the number of patients achieving complete remission of the disease. This consensus document carried out by the Spanish Group for the Study of Glomerular Diseases (GLOSEN) provides practical and updated recommendations, based on the best available evidence and clinical expertise of participating nephrologists.

Keywords: immunosuppressive treatment; kidney biopsy; lupus nephritis; nephrotic syndrome; renal outcomes.

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Conflict of interest statement

J.E.R.-R.: paid lectures and consultancy for GSK, Otsuka and Alexion. C.G.-C.: paid lectures and consultancy for AstraZeneca, Esteve, Novonortis, Boehringer Ingelheim, Astellas, Otsuka, Novartis, Mundifarma, Baxter and Vifor. A.I.Á.: nothing to disclose. M.Espino: paid lectures for Alexion. M.Espinosa: paid lectures and consultancy for Alexion. G.F.-J.: paid lectures for GSK and Otsuka. X.F.: paid consultancies for Otsuka and Novartis. M.G.: paid lectures and consultancy for GSK. M.M.: nothing to disclose. E.M.: paid lectures for GSK. L.F.Q.: paid lectures for GSK and Otsuka. M.P.: paid lectures and consultancy for GSK, Osuka, Novartis, Apellis, Alexion, Sanofi, Vifor and Travere.

Figures

Figure 1:
Figure 1:
Indications of kidney biopsy in patients with SLE and major histological classes according to the 2018 ISN/RPS classification.
Figure 2:
Figure 2:
Objectives in the treatment of LN. RBC/hpf: red blood cells per high-power field.
Figure 3:
Figure 3:
Treatment of classes I and II. CV: cardiovascular.
Figure 4:
Figure 4:
Initial treatment for classes III/IV ± V. HCQ: initial dose 4–5 mg/kg/day (maximum 400 mg daily). If eGFR <30 mL/min/1.73 m2, do not exceed 200 mg daily. MPAA: dose equivalent to 2 g of MMF. Cyclophosphamide: Eurolupus regimen preferred (6 biweekly i.v. pulses of 500 mg each, cumulative dose = 3 g). CNI: cyclosporine (initial dose 100–200 mg daily, blood target level 60–100 ng/mL), tacrolimus (initial dose 0.05–0.07 mg/kg/day, blood target level 4–7 ng/mL), voclosporine (23.7 mg twice daily for 1–2 years, no blood target level required). Belimumab: 10 mg/kg i.v. on days 1, 15 and 29, then every 28 days. i.v.: intravenous.
Figure 5:
Figure 5:
Initial treatment for class V (membranous). HCQ: initial dose 4–5 mg/kg/day (maximun 400 mg daily). If eGFR <30 mL/min/1.73 m2, do not exceed 200 mg daily. MPAA: dose equivalent to 2 g of MMF. CNI: cyclosporine (initial dose 100–200 mg daily, blood target level 60–100 ng/mL), tacrolimus (initial dose 0.05–0.07 mg/kg/day, blood target level 4–7 ng/mL), voclosporine (23.7 mg twice daily for 1–2 years, no blood target level required). CV: cardiovascular.
Figure 6:
Figure 6:
Maintenance treatment for classes III/IV ± V and V. CV: cardiovascular; MRA: mineralocorticoid receptors antagonists.
Figure 7:
Figure 7:
Recommendations and therapeutic options in refractory LN.
Figure 8:
Figure 8:
Prevention and treatment of relapses.
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