Lupus Nephritis Treatment Guidelines

Induction Phase

The European League Against Rheumatism (EULAR) recommends a low-dose intravenous cyclophosphamide regimen of 500 mg every 2 weeks for a total of 6 doses, combined with glucocorticoids, for the treatment of lupus nephritis 1, 2, 3
The American College of Rheumatology suggests that the low-dose regimen is substantially lower than the NIH high-dose regimen, which is 0.5-0.75 g/m² monthly for 6 months 2, 6
The low-dose regimen was developed specifically for European populations but has been used successfully in non-European populations 2, 3
The initial IV methylprednisolone pulses should be 500-2500 mg total, typically 500-750 mg for 3 consecutive days 1, 2, 4
Oral prednisone should be given at a dose of 0.3-0.5 mg/kg/day for 4 weeks, then tapered to ≤7.5 mg/day by 3-6 months 1, 2, 7

The EULAR recommends azathioprine 2 mg/kg/day or mycophenolate mofetil 1-2 g/day for maintenance therapy, combined with low-dose prednisone (2.5-7.5 mg/day) 1, 2, 4
The maintenance duration should be a minimum of 3-5 years 1, 4, 5
Patients who received cyclophosphamide induction should transition to azathioprine or MMF 3, 4
Switch from MMF to azathioprine at least 3-6 months before planned conception, as MMF is teratogenic 1, 8

Hydroxychloroquine should be given at a dose of ≤5 mg/kg/day, adjusted for GFR if <30 mL/min, with ophthalmologic monitoring after 5 years 1, 2, 7
ACE inhibitors or ARBs should be used for proteinuria >500 mg/g or hypertension 4, 5, 9
Statins should be used for persistent dyslipidemia, with a target LDL <100 mg/dL 4, 5, 9

The treatment targets include evidence of proteinuria improvement with GFR stabilization at 3 months, ≥50% reduction in proteinuria at 6 months, and proteinuria <0.5-0.7 g/24 hours with near-normal GFR at 12 months 1, 6, 8
Monitoring parameters should include body weight, blood pressure, serum creatinine, eGFR, serum albumin, proteinuria, urinary sediment, C3/C4, anti-dsDNA, and complete blood count at each visit 4, 5, 9

The Eurolupus regimen was originally developed in predominantly Caucasian European populations, but has been successfully used in non-European populations 10, 3
African Americans and Hispanics may respond better to MMF than cyclophosphamide 3
High-dose cyclophosphamide should be considered in patients with adverse prognostic factors, such as nephritic urine sediment, impaired renal function, or crescents or necrosis in >25% of glomeruli 2, 6, 7