Treatment of lupus nephritis in adult patients


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Treatment of lupus nephritis in adult patients

  1. 1. Treatmentoflupusnephritisinadultpatients
  2. 2. AlgorithmsTreatment of lupus nephritis in adult patientsSundeep UpadhyayaIndraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, IndiaAbstractThis set of management principles which is based on personalpractice and refers to the American College of RheumatologyGuidelines1and the European league against Rheumatologyrecommendations2are particularly suited to India and theIndian Ethnic population. It also takes into account the pre-vailing principles of treatment widely accepted among therheumatologists of the Indian subcontinent.The ISN/RPS classification of lupus nephritis (2003)3definesnephritis in the clinical setting of a patient with SLE, who hasproteinuria >500 mg per day or 3þ proteinuria by dipsticksand/or active urinary sediment. This classification broadlylists classes of lupus nephritis from Class I to Class VI. Thisalgorithm outlines the treatment plan for Class III/IV andClass V lupus nephritis. Some notable points e Cyclo-phosphamide (CYC) in the Indian Subcontinent is usuallyinitiated at a dose of 750 mg/m,2and final doses are adjustedto a nadir of leucocyte counts at (2 weeks e 3000e4000/mL)follow up. The “EUROLUPUS” regime (500 mg CYC everyfortnight  3 months) for induction treatment is valid mostlyfor certain white European ethnic groups. Not mentioned inthis algorithm are I.V. boluses of Methyl Prednisolone com-monly used in India and the world over for induction (basedon expert opinion only).Class I/II lupus nephritis needs no specific treatment andfor 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-mendations2Steroids and AZA may be used. Both the ACRguidelines and Rheumatology practitioners all over the worldrecommend 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 forMMF (Mycophenolate Mofetil) doses, the Asian/Indian popu-lation can make do with 2 g per day for induction instead of 3 gper day, except when there are significantly more crescentsseen on histopathology and there is significant activity (asdeemed by the histopathologist).For younger female patients, where MMF cannot be used(severe disease, extensive crescents on histopathology orhave failed MMF therapy) cyclophosphamide therapy can beand is very frequently used along with luprolide to preventgonadal toxicity. As for pregnant patients, in my personalpractice (and also as spelled out in the ACR lupus guidelines),the services of an obstetricianegynaecologist, who hasexperience with treatment of lupus patients should beemployed. Adjunctive therapy like Calcium, Vitamin D sup-plements, & Iron and folic acid therapy are also mandatory.The following is the accepted norm for pregnant lupusnephritis patients: (a) no activity on histopathology, no spe-cific therapy; (b) for minimal mild activity, hydroxy-chloroquine 200e400 mg per day and (c) for significantnephritis, glucocorticoids (GC) (þ), Azathioprine (AZA). Someother notable highlights of my personal practice are the def-initions of “improved/not improved” in the algorithm (theseare loosely based on the work of several Indian investigatorsand the ACR guidelines). Also of note, is the omission ofAzathioprine for induction; it is now the second agent ofchoice after MMF for maintenance therapy1,2(usually 3 years).E-mail address: online at www.sciencedirect.comjournal homepage: p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 8 5 e8 60976-0016/$ e see front matter
  3. 3. r e f e r e n c e s1. 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 lupus nephritis. Ann Rheum Dis. 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.a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 8 5 e8 686
  4. 4. Apollohospitals: