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Patient Goals in Treatment of LN

Alvin Wells, MD, PhD, and Jorge Larranaga, MD, highlight the goals of treatment for patients with lupus nephritis.

Jorge Larranaga, MD: The goals of therapy for patients with lupus nephritis have changed over time. Based on the MAINTAIN trial in 2016, we know protein reduction is critical for long-term renal outcome. Therefore, prompt diagnosis, biopsies, and therapeutic interventions are important for these patients in focusing on reducing proteinuria, obtaining a bland urinalysis, and trying to get the urine PCR [protein-creatinine ratio] less than 700 mg/g, depending on what you read, or less than 500 mg/g, depending on the study.

We have lacked data in academic research for over 40 years regarding the management of lupus nephritis. The lack of data has left us with a status quo of partial remission—in essence, having patients with protein leakages greater than 1.5 g or above. We often relied on a 50% reduction, which we clearly know based on the data hasn’t been sufficient to treat these patients to a complete remission. Depending on the articles you read, complete remissions and partial remissions are varied. But overall, the consensus is that if we’re able to get a protein excretion less than 700 mg per day, those patients do quite well with less deterioration from a renal perspective in outcome.

We also know the European guidelines have been well defined and accepted by the US guidelines, where the reduction of urine PCR with the standard of therapy of blood pressure control, RAS blockade, etc, has led to the backbone of management of these patients along with the standard of care that has been set forward. Dr [Gerald] Appel, Dr [Gabriel] Contreras from the University of Miami, and other colleagues [showed the value of] MMF [mycophenolate mofetil]–Cytoxan therapy and steroid therapies, which were the standard of therapy for many years until 2020. We now have 2 medications with good outcomes that we’re able to add to the revolver and treat the complexity of these patients that we haven’t had in 40 years.

Alvin Wells, MD, PhD: I tell my patients with lupus nephritis that we need to set some goals. I sit down with them and ask, “What are your goals? What do you want to do?” They say, “Dr Wells, I don’t want to have pain or fatigue. I don’t want the swelling in my ankles to continue.” As a rheumatologist, I want to make sure your disease is under control, that you don’t get end-stage kidney disease and end up on dialysis. We try to put those features together. Even though we talk about kidney disease, some of the biggest things that drive patients into the clinic are swelling of their ankles, weight gain, and fatigue. These patients might go to bed at night and think they’re sleeping for 6 or 7 hours, but when they wake up, they feel like they’ve been hit by a truck. That’s because the immune system is turning like a machine and not able to shut off unless we use aggressive medications.

With patients with lupus and lupus nephritis, I say “Let’s talk about our goals.” Let’s see if I can minimize certain drugs, such as corticosteroids, which have some adverse effects we don’t like for long-term [use]. Let’s see if we can maximize and preserve their kidney function long term so that a 30-year-old woman who presents with lupus nephritis can have as close to a normal life expectancy as possible.

Transcript edited for clarity.

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