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Optimizing Management of Lupus Nephritis - Episode 4

Emphasizing Urgent Treatment and Guideline-Directed Therapies for Patients with LN

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Jorge Larranaga, MD, provides his opinion regarding the criticality of urgency in LN treatment.

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Jorge Larranaga, MD: The urgency to treat in lupus nephritis is of utmost importance. Time is nephron survival. We recognize that lupus nephritis can lead to a 45-fold increase in kidney failure and end-stage renal disease. We also recognize that the involvement of lupus nephritis can lead to significant cardiovascular complications: about an 8-fold increase of myocardial infarctions and a 4-fold increase in myocardial death, all associated with the risk of proteinuria and renal involvement. In addition to this, hospitalizations, the length of stay, the cost, and the complications associated with patients with lupus in a hospital setting lead to even more complicated status than the disease itself.

The urgency is quite real, and we should prompt ourselves to [aim for] early diagnosis, early biopsies, and early interventions. We often have significant impediments of our approach to these patients, but it should be treated how cardiology treats patients with acute angina and myocardial infarction. There should be an increased aggressiveness and urgency to treat these patients because they can quickly progress to a very critical state.

In 2012, we were following guidelines from the American College of Rheumatology [ACR], which recommended to monitor patients every 6 months. In reality, 58% of the patients aren’t being screened in a 6-month basis with the standard laboratory data that one would expect. In addition, it was left up to the physicians regarding how to treat and manage the different types and stages of lupus nephritis depending on the findings. There were no direct criteria or guidance with respect to some of the stages. In addition to monitoring patients who had more than 1 g of protein excretion along with hematuria, those patients will be indicated for a renal biopsy.

The list goes on with respect to the 2012 ACR guidelines that we followed for many years, until 2019, when the European Alliance of Associations of Rheumatology and the European Renal Association and European Dialysis and Transplant Association got together and gave us new guidelines, which we’re now following and which have been [adopted] by the American guidelines. Those are the latest that we have. Those are much more stringent guidelines as far as intervention. We recognize that the threshold for biopsy for patients with lupus nephritis has been lowered to 500 mg of protein excretion from 1000 mg per day. Patients who have microscopic hematuria should be biopsied, which is [recommended by the] new guidelines, along with patients with RBCs [red blood cells], CAS, or dysmorphic red blood cells. In addition, we have better guidance with respect to our target goal, where we should be regarding intervention based on a bland urinalysis or urine protein reduction.

Transcript edited for clarity.

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