This document summarizes key information about lupus nephritis (LN) from a lecture given by Dr. Hussein Sheashaa. It begins with an outline of topics to be covered, including histopathology/biopsy, predictors of outcome, treatment approaches, and special situations. Regarding biopsy findings, it indicates that class IV LN is most common and describes revised classification guidelines. Treatment principles focus on early, aggressive therapy to achieve remission and prevent flares/progression. Standard induction therapies are discussed as well as new options like voclosporin. Maintenance strategies and treatment algorithms are presented. Predictors of poor outcome and management of special cases like pregnancy and refractory LN are also summarized.

1. Lupus Nephritis
Hussein Sheashaa, MD, FACP
Professor of Nephrology, Urology and Nephrology Center and Director of
Medical E-Learning Unit, Mansoura University, ESNT-CME Chair and Executive
Director of ESNT- Virtual Academy: http://lms.mans.edu.eg/esnt/
GN Master Class, Monday, 21 October, 2019

4.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

6. 2019

7. Curr Opin Rheumatol November 2019, 31:682–688
Lupus Nephritis:
Why?

8. Lupus Nephritis:
Egypt Jan 1980 to June 2016

9.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

10.  Glomerular
 Immune complex glomerulonephritis
 Pauci-immune
 RPGN
 Tubulointerstitial
 Vascular
 APLN
 Vasculitis
 RVT
Renal Pathology:
Spectrum in SLE

11. Lupus (2017) 26, 1228–1234
LN Classes:
What is The Most Common Class?

12. Active Lesions

13. Active Lesions

14. Chronic Lesions (C)

15. IgG

16. Clin J Am Soc Nephrol 11: 585–592, 2016
Lupus Nephritis:
Lupus Podocytopathy

17. Kidney International (April 2018) 93, 789–796
Lupus Nephritis Diagnosis:
Revision of ISN/RPS

18. Pathological Indices
 Activity:
1. Mesangial proliferation
2. Hyaline lesions
3. Cellular crescents
4. Necrosis
5. Neutrophils/ glomerulus
6. Interstitial inflammation
X2
X2
 Chronicity:
1. Sclerotic glomeruli
2. Fibrous crescents
3. Atrophic tubules
4. Interstitial fibrosis
< 25%: 1
25-50%: 2
>50%: 3
AI /24
CI /12

19. Reumatologia 2016; 54, 2: 61–66
Lupus Nephritis:
Biopsy Recommendations

20. Proliferative Lupus N:
Histological Versus Clinical Remission
Nephrol Dial Transplant (2017) 32: 1338–1344
One-third of patients who achieved a complete clinical response
after induction had persistently high histologic activity
62% of patients who had complete histologic remission
on rebiopsy were still clinically active.

21. Lupus Nephritis:
Current Algorithms
Clin J Am Soc Nephrol. 2017 May 8;12(5):825-835.

22. Kidney International 2019, in press
Lupus Nephritis:
Kidney Biopsy to Guide Maintenance IS

23. Q

24.  If the biopsy findings are:
 60% cellular crescents, no necrosis, 70% hyaline
lesions, 70 % mesangial proliferation, 30 % interstitial
inflammation, 20 % neutrophil infiltration,
glomerulosclerosis 10% and interstitial fibrosis 10 %
Q
Calculate AI and CI

25.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

26. Curr Opin Rheumatol November 2019, 31:682–688
Lupus Nephritis:
Predictors of Poor Outcome

27. Curr Opin Rheumatol November 2019, 31:682–688
Lupus Nephritis:
Predictors of Poor Outcome

28. Classification and Reporting of GN
Nephrol Dial Transplant (February 2019) 34: 193–199

29. Lupus Nephritis:
Impact of Antiphospholipid Antibodies
Lupus (2019) 28, 1460–1467
53/149 (35.6%) patients with biopsy-proven LN

30. Medicine (Baltimore). 2017 Sep;96(37):e8024.
LN Outcome Prediction:
Score System
< 10 11-20 > 20 incidences of ESRD in these 3 groups
were 2.7%, 32.5%, and 79.4%,

31.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

33. Treatment of LN:
Principles
 As early as possible
 Aggressive enough to obtain complete remission
 Able to prevent renal flare
 Delay or prevent progression to ESRD
Infection/
MalignancyDisease
Control

34. Treatment of LN:
Standard of Care
J Am Soc Nephrol 27: 2929–2939, October 2016

35. J. Comp. Eff. Res. (2019) 8(13), 1125–1141
Lupus Nephritis:
Tacrolimus

36. Kidney International (2019) 95, 219–231
Voclosporin for LN
(AURA Trial-Phase 2)
versus placebo; *P= 0.046, **P <0.001, +P= 0.20, ++P= 0.026
(Aurinia Renal Response
in Active Lupus With
Voclosporin [AURORA-
Phase 3]

37. Treatment of LN:
Maintenance Therapy

38. Treatment of LN:
Maintenance Therapy

39. Am J Kidney Dis. September 2017;70(3):324-336
Treatment of Proliferative
Lupus Nephritis

40. Immunosuppression
for MN

41. Management of SLE:
2019 EULAR Recommendations
Ann Rheum Dis 2019;78:736–745.

42. Clin J Am Soc Nephrol 11: 585–592, 2016
Lupus Nephritis:
Lupus Podocytopathy

43. Lupus Nephritis:
B-cell Therapy
Nephrol Dial Transplant (2019) 34: 22–29

44. Plasmapheresis

45.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

46. Treatment of LN:
Pregnancy

47. Lupus Nephritis:
Pregnancy?

48. Refractory Lupus Nephritis:
Management Algorithm
Kidney International (2019) 95, 281–295

49.  When to transplant a lupus nephritis ESRD?
Q

50. Recurrence
Curr Opin Nephrol Hypertens. 2017 Nov;26(6):501-508.

51. Concluding Remarks

52. Treatment of LN:
Algorithm of Treatment

55. ESNT Virtual Academy:
http://lms.mans.edu.eg/esnt/
27831 Users
21 October 2019