A Kidney Disease: Improving Global Outcomes (KDIGO) committee has released a new 2021 clinical practice guideline that updates their 2012 recommendations for the management of lupus nephritis (LN) and other glomerular diseases.
The new guideline presents recommendations and practice points on various glomerular diseases, including LN, IgA nephropathy and IgA vasculitis, membranous nephropathy, nephrotic syndrome, minimal change disease, focal segmental glomerulosclerosis, infection-related glomerulonephritis (GN), antineutrophil cytoplasmic antibody vasculitis, and anti-glomerular basement membrane antibody GN. For the first time, the guideline also addresses the subtype of complement-mediated diseases. For each glomerular disease, guidance is offered on diagnosis, prognosis, treatment, and special situations.
The 2021 guideline, authored by Brad H. Rovin, MD, of The Ohio State University Wexner Medical Center in Columbus, Ohio, and colleagues and published in Kidney International, discusses new management approaches for LN. Antimalarials may reduce flares, decrease organ damage, and aid immunosuppression, the committee stated. Clinicians should also adopt a holistic approach to LN management by reducing patients’ risks for cardiovascular complications, proteinuria, infection, bone injury, ultraviolet light exposure, cancer, premature ovarian failure, and unplanned pregnancy. Interventions involve screenings, diet, exercise, weight optimization, vaccination, supplementation, and medication.
For proliferative LN (class 3/4 with or without class 5), many patients may need less intense immunosuppression, including glucocorticoids, the committee highlighted. For induction therapy, they suggested 0.25 to 0.5 g/d of intravenous methylprednisolone for 3 days, followed by 0.6 to 1 mg/kg/d of oral prednisolone with tapering by 3 months along with intravenous low-dose cyclophosphamide or mycophenolate mofetil (MMF). Very severe proliferative LN warrants more intense immunosuppression. Management of pure class 5 LN has not changed since the 2012 guideline.
The authors pointed out that management recommendations for LN “are poised to change significantly in the coming months because several high-quality [randomized controlled trials] of novel therapies have recently been successfully completed. These approaches will be incorporated into the guideline as the community understands how best to apply the new agents in the context of existing regimens.”
In January 2021, the FDA approved the addition of the novel calcineurin inhibitor, voclosporin, to prednisone and MMF for active LN. Voclosporin is considered glucocorticoid-sparing. Multitarget therapy is currently being reassessed. Biologics including belimumab, rituximab, and abatacept also continue to be studied. A mycophenolic acid analog is recommended for ongoing immunosuppression.
The overall duration of immunosuppression and what constitutes a meaningful response to LN treatment remain hot topics.
Rovin BH, Adler SG, Barratt J, et al. Executive summary of the KDIGO 2021 guideline for the management of glomerular diseases. Kidney Int. 100;753-779.doi:10.1016/j.kint.2021.05.015