Pay attention to lupus nephritis, starting from treatment

Lupus nephritis (LN) is the most common secondary immune glomerular disease in China.
It is caused by systemic lupus erythematosus involving the kidneys.
It is also an important cause of death in patients with systemic lupus erythematosus.

The main treatment goal of LN is to control the disease and prevent it from progressing to chronic kidney disease.

However, current treatment strategies cannot meet clinical needs.

Recently, a review in the journal J Clin Med (IF: 3.
303) summarized the existing treatment strategies and recommendations for LN, and proposed that improving the prognosis of LN may be done from two aspects: 1) Improving the treatment of standards, in addition to clinical In addition to the parameters, reference should also be made to pathological results (such as kidney biopsy); 2) The treatment of LN should be gradually changed from traditional sequential treatment to combination treatment.

LN's existing treatment strategies and recommended overall treatment strategies The ultimate treatment goal of LN is to improve the long-term survival rate of patients and kidneys and improve the quality of life of patients; the short-term goal is to completely relieve the clinical symptoms and laboratory signs of patients as much as possible.

In clinical practice, the specific treatment plan for LN patients depends on their disease type (ISN/RPS classification criteria).

Current treatment recommendations The investigator indicated that if there are no contraindications, angiotensin converting enzyme inhibitor/angiotensin II receptor antagonist and hydroxychloroquine (5mg/kg/d, if necessary, reduce the dose when the renal damage is severe) can be used as LN treatment The basic medication.

At the same time, the treatment of LN includes induction therapy and maintenance therapy.

Induction therapy of type III/IV (±V) LN: In the early stage, intravenous injection of hormone (methylprednisolone 500-2500mg), then switch to oral hormone (prednisone 0.
3-0.
5mg/kg/d, 4 weeks ; The dose drops to ≤5-10mg/d at the 3rd month).

During the whole process, patients can use mycophenolate mofetil (2g/d) or cyclophosphamide (intravenous injection).

Another treatment option is the combination of mycophenolate mofetil (1g/d) and calcineurin inhibitor (tacrolimus 4mg/d).

Maintenance treatment of type III/IV(±V) LN: After the induction therapy is completed, LN patients need to receive maintenance treatment (at least 3 years).
During this process, the treatment plan of type III/IV(±V) LN can be On the basis of mycophenolate mofetil (2g/d)/azathioprine (2mg/kg/d), combined with hydroxychloroquine and oral prednisone (2.
5-5mg/d, patients in complete remission may not use it).

In addition to the above treatment options, LN treatment measures also include controlling blood pressure and preventing hormonal side effects, such as giving patients vitamin D3 supplements and encouraging patients to exercise properly.

How to improve the prognosis of LN patients? Researchers believe that by improving the treatment of standards and changing the treatment plan from sequential treatment to combination treatment, the prognosis of LN patients may be improved.

Improving the treatment of the target Target treatment is a common strategy in the treatment of inflammation and autoimmune diseases.

At present, in the treatment of LN, proteinuria is the main clinical parameter.

Studies have confirmed that after 1 year of treatment, LN patients have proteinuria <0.
7g/d, which can be used as a predictor of good kidney prognosis.

The researchers pointed out that repeated kidney biopsy after 1 year of immunosuppressive therapy may help to screen patients who need intensive treatment, which can improve the prognosis of these patients.

Therefore, the researchers suggest that in the treatment of LN, in addition to clinical parameters such as proteinuria, pathological results such as kidney biopsy can also be referred to.

Converting sequential treatment to combination treatment Researchers have proposed a new treatment model, that is, switching from sequential treatment to combination treatment, and said that existing studies have proven that combination treatment is better than existing sequential treatment.

The first successful LN combination regimen was a combination of mycophenolate mofetil (MMF) and tacrolimus (TAC).

A large Chinese study showed that in patients with LN, compared with intravenous cyclophosphamide (based on the NIH recommended dose), the complete renal response rate of MMF and TAC for 6 months was almost doubled.

However, this program may only be applicable to Asian patients.

In addition, the combination therapy of mycophenolate mofetil (MMF) and voclosporine (VOC) also showed good efficacy.

Phase II (AURA) and Phase III (AURORA) trials have shown that in patients with LN, the combined treatment of MMF and VOC is more effective than MMF alone.

However, there are only short-term data (up to 12 months) and no long-term efficacy data.

Therefore, the efficacy of combined treatment of VOC and MMF needs to be confirmed by long-term trials.

Summary Generally speaking, the clinical use of existing standard treatments can alleviate the symptoms of LN patients and prevent their progression to chronic kidney disease.

In addition, in the treatment of LN, referring to the results of kidney biopsy may help reduce the number of patients who progress from LN to chronic kidney disease.

At the same time, recent trials have shown the efficacy of combination therapy.

Researchers speculate that combination therapy may become a new model for the treatment of LN.

References: 1.
Chinese Lupus Nephritis Diagnosis and Treatment Guidelines Compilation Group.
Chinese Lupus Nephritis Diagnosis and Treatment Guidelines[J].
Chinese Medical Journal, 2019(44): 3441-3455.
2.
Tamirou F, Houssiau FA.
Management of Lupus Nephritis.
J Clin Med[J].
2021 Feb 9; 10(4): 670.