Initiating Dialysis in Lupus Nephritis

Standard Dialysis Indications Apply

The European League Against Rheumatism (EULAR) and European Renal Association (ERA-EDTA) guidelines state that dialysis in lupus nephritis should be initiated using standard end-stage kidney disease (ESKD) criteria, and all methods of kidney replacement therapy can be safely used in SLE patients 1
Uremic symptoms, such as encephalopathy, pericarditis, and bleeding diathesis, are indications for dialysis initiation 2
Severe metabolic acidosis refractory to medical management is a condition that requires dialysis 3
Hyperkalemia unresponsive to conservative measures is a condition that requires dialysis 1
Volume overload causing pulmonary edema despite diuretics is a condition that requires dialysis 4
Severe electrolyte disturbances threatening life are indications for dialysis initiation 1

A GFR <15 mL/min/1.73 m² (CKD stage 5/ESKD) typically requires renal replacement therapy, though the exact timing depends on clinical symptoms rather than the number alone 1
A GFR <30 mL/min/1.73 m² (CKD stage 3b-4) requires close monitoring but not automatic dialysis, as kidney biopsy decisions at this level should be based on kidney size and evidence of active disease (proteinuria, active urinary sediment) 5, 6

The EULAR/ERA-EDTA guidelines recommend continuing immunosuppression guided by extrarenal manifestations once on dialysis 1
Monitoring for treatment response at 3 months (evidence of proteinuria improvement) and 6 months (≥50% proteinuria reduction) is crucial 2, 3
Avoiding premature treatment switches in patients with nephrotic-range proteinuria at baseline is recommended, as they may require an additional 6-12 months to achieve complete response 2, 3

Transplantation should be preferred over chronic dialysis when feasible, with extrarenal lupus being clinically and ideally serologically inactive for at least 6 months before transplantation 1, 4, 5
Superior outcomes are achieved with living donor and pre-emptive transplantation (before dialysis initiation) 1, 4, 5
Antiphospholipid antibodies should be measured during transplant preparation due to increased vascular thrombosis risk in the transplanted kidney 1, 4, 5

Delaying immunosuppressive treatment based solely on low GFR if there is evidence of active disease (proteinuria, active sediment, normal kidney size) should be avoided 5, 6
Assuming dialysis is inevitable in advanced CKD should be avoided, as many patients stabilize with appropriate management 1
Using GFR alone to determine dialysis timing should be avoided, as clinical symptoms and complications should guide the decision 1
Being aware of increased infection risk in patients on peritoneal dialysis who remain on immunosuppressive agents is crucial 5
Monitoring for vascular access thrombosis in patients with antiphospholipid antibodies is recommended 5