Update on Lupus Nephritis: Looking for a New Vision

Abstract

Lupus nephritis (LN) is one of the most common manifestations of systemic lupus erythematosus (SLE), affecting approximately 40% of patients with lupus. It represents a major risk factor for morbidity and mortality, and 10% of patients with LN will develop end-stage kidney disease (ESKD). Therefore, there are a number of areas for improvement in the field of LN such as the search for new clinical biomarkers with a more accurate correlation with lupus activity and the redefinition of the histological classification into different subgroups in order to guide a personalized treatment. Although the role of protocol repeat kidney biopsies in LN is controversial, recent publications suggest that repeat histological assessment can be useful in guiding therapeutic decisions that may yield toward precision medicine. In the last decade, LN therapy has remained largely unchanged, with a probability of achieving complete or partial remission not exceeding 60–70%. Thus, optimization of old treatment strategies and search for new agents are urgently needed in order to improve outcomes such as mortality or development of ESKD. Future trials should focus in addressing unanswered issues such as the appropriate dose and duration of immunosuppressive treatment, timing of steroid withdrawal, and drug toxicity. In addition, data are still lacking regarding pregnancy and kidney transplantation in LN and knowledge about these important areas is essential for the management of a subset of patients with SLE. In summary, several major gaps are still present in the therapeutic approach and follow-up of patients with LN. The development of new clinical trial designs will be crucial in the search to improve long-term outcomes.

Something new about prognostic factors for lupus nephritis? A systematic review

“…The mortality is greater in patients with SLE and nephritis as compared to patients with SLE without nephritis. 1 Although recent studies show a decrease in the incidence of patients requiring renal replacement therapy for lupus nephritis (LN), 2 we must not forget that LN occurs in 30-45% of SLE patients, and 10-25% of them will develop endstage renal disease (ESRD) 3,4 over the course of their disease.…”

The potential use of serum interleukin-21 as biomarker for lupus nephritis activity compared to cytokines of the tumor necrosis factor (TNF) family

“…The combination of novel and traditional biomarkers has enhanced the identification of activity patterns. 56 Combined monitoring of 24-h proteinuria and serum IL-21, in parallel, would increase the power of differential diagnosis of active and inactive LN to 98% as compared to serum IL-21 (sensitivity: 70%) or 24-h proteinuria (sensitivity: 93%) alone. This may result from the different mechanisms of both biomarkers, so that those two markers reflect different aspects of LN activity.…”

Fish oil enhanced the efficacy of low-dose cyclophosphamide regimen for proliferative lupus nephritis: a randomized controlled double-blind trial

“…The data released by Chinese SLE treatment and research group (CSTAR) showed that the global average prevalence of SLE was 12-39/100,000, and the prevalence of SLE in China was 30-70/100,000, which ranked second in the world (19). SLE patients have a 50% chance of developing LN, and the degree of kidney involvement directly affects the prognosis of SLE (20). So, it is important to understand the pathogenesis, related markers, and the treatment of LN.…”