2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis

Lisa R Sammaritano¹, Anca Askanase², Bonnie L Bermas³, Maria Dall'Era⁴, Alí Duarte-García⁵, Linda T Hiraki⁶, Brad H Rovin⁷, Mary Beth F Son⁸, Anthony Alvarado⁹, Cynthia Aranow¹⁰, April Barnado¹¹, Anna Broder¹², Hermine I Brunner¹³, Vaidehi Chowdhary¹⁴, Gabriel Contreras¹⁵, Christele Felix¹⁶, Elizabeth D Ferucci¹⁷, Keisha L Gibson¹⁸, Aimee O Hersh¹⁹, Peter M Izmirly²⁰, Kenneth Kalunian²¹, Diane Kamen²², Brandi Rollins²³, Benjamin J Smith²⁴, Asha Thomas²⁵, Homa Timlin²⁶, Daniel J Wallace²⁷, Michael Ward²⁸, Muayad Azzam²⁹, Christie M Bartels³⁰, Joanne S Cunha³¹, Kimberly DeQuattro³², Andrea Fava²⁶, Gabriel Figueroa-Parra³³, Shivani Garg³⁰, Jessica Greco⁷, Maria C Cuéllar-Gutiérrez³⁴, Priyanka Iyer³⁵, Andrew S Johannemann³⁶, April Jorge³⁷, Shanthini Kasturi³⁸, Hassan Kawtharany²⁹, Jana Khawandi²⁹, Kyriakos A Kirou¹, Alexandra Legge³⁹, Kelly V Liang²⁹, Megan M Lockwood⁴⁰, Alain Sanchez-Rodriguez⁴¹, Marat Turgunbaev⁴², Jessica N Williams⁴³, Amy S Turner⁴², Reem A Mustafa²⁹

Affiliations

¹ Hospital for Special Surgery - Weill Cornell Medicine, New York, New York.
² Columbia University, New York, New York.
³ UT Southwestern Medical Center, Dallas, Texas.
⁴ University of California, San Francisco.
⁵ Mayo Clinic, Rochester, Minnesota.
⁶ The Hospital for Sick Children, Toronto, Ontario, Canada.
⁷ Ohio State University, Columbus.
⁸ Boston Children's Hospital, Boston, Massachusetts.
⁹ Kaiser Permanente, Sacramento, California.
¹⁰ Feinstein Institutes for Medical Research, Manhasset, New York.
¹¹ Vanderbilt University Medical Center, Nashville, Tennessee.
¹² Hackensack University Medical Center, Hackensack, New Jersey.
¹³ Cincinnati Children's Hospital, University of Cincinnati, College of Medicine, Cincinnati, Ohio.
¹⁴ Yale University School of Medicine, New Haven, Connecticut.
¹⁵ University of Miami, Miami, Florida.
¹⁶ Rosedale, New York.
¹⁷ Alaska Native Tribal Health Consortium, Anchorage.
¹⁸ University of North Carolina, Chapel Hill.
¹⁹ The University of Utah, Salt Lake City.
²⁰ NYU Grossman School of Medicine, New York, New York.
²¹ University of California, San Diego.
²² Medical University of South Carolina, Charleston.
²³ Montgomery, Alabama.
²⁴ Florida State University, Tallahassee.
²⁵ The Central Texas Veterans Health Care System, Temple.
²⁶ Johns Hopkins University, Baltimore, Maryland.
²⁷ Cedars-Sinai, Los Angeles, California.
²⁸ Verier Outcomes Research LLC Rockville, Maryland.
²⁹ University of Kansas, Kansas City.
³⁰ University of Wisconsin, Madison.
³¹ Warren Alpert Medical School of Brown University, East Providence, Rhode Island.
³² University of Pennsylvania, Philadelphia.
³³ Mayo Clinic, Rochester, Minnesota, and University Hospital Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
³⁴ Mayo Clinic, Rochester, Minnesota, and Hospital del Salvador, Santiago, Chile.
³⁵ University of California Irvine Medical Center, Orange.
³⁶ Carolina Arthritis Center, Greenville, North Carolina.
³⁷ Massachusetts General Hospital, Boston.
³⁸ Tufts Medical Center, Boston, Massachusetts.
³⁹ Dalhousie University, Halifax, Nova Scotia, Canada.
⁴⁰ Georgetown University Hospital, Washington, DC.
⁴¹ Mayo Clinic, Rochester, Minnesota, and Department of Internal Medicine, The American British Cowdray Medical Center, I.A.P, Mexico City, Mexico.
⁴² American College of Rheumatology, Atlanta, Georgia.
⁴³ Washington University, St. Louis, Missouri.

PMID: 40127995
DOI: 10.1002/acr.25528

Practice Guideline

2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis

Lisa R Sammaritano et al. Arthritis Care Res (Hoboken). 2025 Sep.

. 2025 Sep;77(9):1045-1065.

doi: 10.1002/acr.25528. Epub 2025 May 7.

Authors

Affiliations

¹ Hospital for Special Surgery - Weill Cornell Medicine, New York, New York.
² Columbia University, New York, New York.
³ UT Southwestern Medical Center, Dallas, Texas.
⁴ University of California, San Francisco.
⁵ Mayo Clinic, Rochester, Minnesota.
⁶ The Hospital for Sick Children, Toronto, Ontario, Canada.
⁷ Ohio State University, Columbus.
⁸ Boston Children's Hospital, Boston, Massachusetts.
⁹ Kaiser Permanente, Sacramento, California.
¹⁰ Feinstein Institutes for Medical Research, Manhasset, New York.
¹¹ Vanderbilt University Medical Center, Nashville, Tennessee.
¹² Hackensack University Medical Center, Hackensack, New Jersey.
¹³ Cincinnati Children's Hospital, University of Cincinnati, College of Medicine, Cincinnati, Ohio.
¹⁴ Yale University School of Medicine, New Haven, Connecticut.
¹⁵ University of Miami, Miami, Florida.
¹⁶ Rosedale, New York.
¹⁷ Alaska Native Tribal Health Consortium, Anchorage.
¹⁸ University of North Carolina, Chapel Hill.
¹⁹ The University of Utah, Salt Lake City.
²⁰ NYU Grossman School of Medicine, New York, New York.
²¹ University of California, San Diego.
²² Medical University of South Carolina, Charleston.
²³ Montgomery, Alabama.
²⁴ Florida State University, Tallahassee.
²⁵ The Central Texas Veterans Health Care System, Temple.
²⁶ Johns Hopkins University, Baltimore, Maryland.
²⁷ Cedars-Sinai, Los Angeles, California.
²⁸ Verier Outcomes Research LLC Rockville, Maryland.
²⁹ University of Kansas, Kansas City.
³⁰ University of Wisconsin, Madison.
³¹ Warren Alpert Medical School of Brown University, East Providence, Rhode Island.
³² University of Pennsylvania, Philadelphia.
³³ Mayo Clinic, Rochester, Minnesota, and University Hospital Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México.
³⁴ Mayo Clinic, Rochester, Minnesota, and Hospital del Salvador, Santiago, Chile.
³⁵ University of California Irvine Medical Center, Orange.
³⁶ Carolina Arthritis Center, Greenville, North Carolina.
³⁷ Massachusetts General Hospital, Boston.
³⁸ Tufts Medical Center, Boston, Massachusetts.
³⁹ Dalhousie University, Halifax, Nova Scotia, Canada.
⁴⁰ Georgetown University Hospital, Washington, DC.
⁴¹ Mayo Clinic, Rochester, Minnesota, and Department of Internal Medicine, The American British Cowdray Medical Center, I.A.P, Mexico City, Mexico.
⁴² American College of Rheumatology, Atlanta, Georgia.
⁴³ Washington University, St. Louis, Missouri.

PMID: 40127995
DOI: 10.1002/acr.25528

Abstract

Objective: The objective is to provide evidence-based and expert guidance for the screening, treatment, and management of lupus nephritis.

Methods: The Core Team developed clinical questions for screening, treatment, and management of lupus nephritis using the PICO format (population, intervention, comparator, and outcome). Systematic literature reviews were completed for each PICO question, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the quality of evidence and to formulate recommendations. The Voting Panel achieved a consensus ≥70% on the direction (for or against) and strength (strong or conditional) of each recommendation.

Results: We present 28 graded recommendations (7 strong, 21 conditional) and 13 ungraded, consensus-based good practice statements for the screening and management of lupus nephritis. Our recommendations focus on the unifying principle that lupus nephritis therapy is continuous and ongoing, rather than consisting of discrete induction/initial and maintenance/subsequent therapies. Therapy should include pulse glucocorticoids followed by oral glucocorticoid taper and two additional immunosuppressive agents for 3-5 years for those achieving complete renal response.

Conclusion: This guideline provides direction for clinicians regarding screening and treatment decisions for management of lupus nephritis. These recommendations should not be used to limit or deny access to therapies, as treatment decisions may vary due to the unique clinical situation and personal preferences of each individual patient.

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References

REFERENCES

1. Izmirly PM, Parton H, Wang L, et al. Prevalence of systemic lupus erythematosus in the United States: Estimates from a meta‐analysis of the Centers for Disease Control and Prevention National Lupus Registries. Arthritis Rheumatol 2021;73:991–996.
1. Hocaoǧlu M, Valenzuela‐Almada MO, Dabit JY, et al. Incidence, prevalence, and mortality of lupus nephritis: a population‐based study over four decades using the Lupus Midwest Network. Arthritis Rheumatol 2023;75:567–573.
1. Tektonidou MG, Dasgupta A, Ward MM. Risk of end‐stage renal disease in patients with lupus nephritis, 1971–2015: a systematic review and Bayesian meta‐analysis. Arthritis Rheumatol 2016;68:1432–1441.
1. Dall'Era M, Cisternas MG, Snipes K, et al. The incidence and prevalence of systemic lupus erythematosus in San Francisco County, California: The California Lupus Surveillance Project. Arthritis Rheumatol 2017;69:1996–2005.
1. Drenkard C, Lim SS. Update on lupus epidemiology: advancing health disparities research through the study of minority populations. Curr Opin Rheumatol 2019;31:689–696.

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2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis

Affiliations

2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis

Authors

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Abstract

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