A highly anticipated session at the ACR Convergence 2024 was dedicated to the 2024 ACR Guideline for the screening, treatment, and management of lupus nephritis (LN). The new guideline emphasizes the importance of prompt kidney biopsy and LN treatment. Triple therapy is proposed as the most desirable therapy, preferring mycophenolic acid analog (MPAA) regimens to cyclophosphamide (CYC) regimens.
The 2024 ACR Guideline for LN provides evidence-based and expert guidance for the screening, treatment, and management of LN in adults and children. This is the ACR’s first LN Guideline since 20121. Dr. Lisa Sammaritano, MD, from Weill Cornell Medicine, in New York, presented the key recommendations2.
- Monitoring proteinuria every 6 to 12 months or during clinical flare is strongly recommended for all patients with systemic lupus erythematosus (SLE) without known LN. The guideline recommends performing kidney biopsy in people with SLE with proteinuria greater than 0.5 g/g and/or impaired kidney function that is not otherwise explained.
- A lower dose of glucocorticoids is conditionally recommended in patients with LN class III/IV or V to minimize toxicity. Pulse intravenous methylprednisolone (250–1,000 mg/day for 1 to 3 days) may be followed by oral prednisone (<5 mg/kg/day, with a maximum of 40 mg/day) with a taper to a target dose of less than or equal to 5 mg/day by 6 months.
- Triple therapy is recommended for class III/IV with or without V, implying glucocorticoids plus two additional immunosuppressive agents. Dr. Sammaritano said: “We prefer MPAA regimens to CYC regimens for reasons of safety, and we recommend MPAA plus belimumab for significant extrarenal manifestations, and MPAA plus calcineurin inhibitors for those patients with high-level proteinuria of greater than or equal to 3 g/g.” She added that if CYC is to be used, the preferred regimen is the Euro Lupus Nephritis Trial low-dose CYC 500 mg intravenous every 2 weeks, with a total of six doses. Explaining why triple therapy is preferred over dual therapy, Dr. Sammaritano said, “We cannot afford to wait for nephron loss to implement the most efficacious therapy.” The total duration of therapy for patients with complete renal response should at least be 3 to 5 years.
A summary of the guidelines was released by the ACR on November 18, 2024 (available on https://rheumatology.org/lupus-guideline). The full guideline is expected to be published by the summer of 2025 and will be updated every year.
Medical writing support was provided by Michiel Tent
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