Multitarget Therapy in Lupus Nephritis
Initial Treatment Options
- The European League Against Rheumatism recommends mycophenolic acid (MPA) at a target dose of 1-2 g/day with a calcineurin inhibitor (particularly tacrolimus), along with glucocorticoids, as the initial treatment for lupus nephritis, especially in patients with nephrotic-range proteinuria 1
- The initial treatment for Class III or IV (±V) lupus nephritis includes mycophenolic acid (MPA) (target dose: 2-3 g/day) with glucocorticoids, low-dose intravenous cyclophosphamide (500 mg every 2 weeks for 6 doses) with glucocorticoids, or multitarget therapy: MPA (1-2 g/day) plus a calcineurin inhibitor (especially tacrolimus) with glucocorticoids 1
- For Class V lupus nephritis, MPA (target dose: 2-3 g/day) with glucocorticoids is recommended as initial treatment due to the best efficacy/toxicity ratio 1
Maintenance Therapy
- The maintenance therapy for patients who responded to initial treatment includes MPA at lower doses (target dose: 1-2 g/day) or azathioprine (2 mg/kg/day), combined with low-dose prednisone (2.5-5 mg/day), and continued for at least 3-5 years 1, 2
Adjunctive Treatments
- Hydroxychloroquine should be co-administered (dose not exceeding 5 mg/kg/day, adjusted for GFR) 1, 3
- Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers should be used for patients with proteinuria (UPCR >500 mg/g) or hypertension 1, 2
- Statins should be used for persistent dyslipidemia (target LDL-cholesterol <100 mg/dl) 1, 2
Monitoring and Treatment Goals
- The treatment aims for preservation or improvement of kidney function, reduction in proteinuria of at least 25% by 3 months, and reduction in proteinuria of at least 50% by 6 months 1
- Regular monitoring should include body weight, blood pressure, serum creatinine, eGFR, serum albumin, proteinuria, urinary sediment, serum C3 and C4, anti-dsDNA antibody levels, and complete blood cell count 2, 4