The Kidney Disease: Improving Global Outcomes (KDIGO) program has published a 2024 clinical practice guideline for the management of lupus nephritis (LN) in Kidney International and its supplements. The full guideline provides updated recommendations for using belimumab and voclosporin as add-on immunosuppressive agents.
“We are thrilled to publish the Lupus Nephritis Guideline, which follows only two years after the publication of the KDIGO Glomerular Diseases Guideline and reflects the latest advancements in the field,” guideline co-chair Brad Rovin, MD, stated in a KDIGO news release. “This guideline offers critical insights into navigating the complexities of LN treatment, especially with the introduction of novel therapies, and highlights the need for individualized therapy selection based on patient-specific factors and clinical scenarios. With ongoing trials evaluating additional novel therapeutics and promising new data on the horizon, the guideline sets the stage for future advancements in the management and treatment of LN.”
An executive summary highlighted some key updates. For initial treatment of proliferative LN, patients with active Class III or IV LN, with or without class V, should initially receive glucocorticoids plus mycophenolic acid analogs (MPAA) or low-dose intravenous cyclophosphamide (dual therapy). Alternately, based on moderate level evidence, patients can receive triple therapy including add-on belimumab with either MPAA or low-dose intravenous cyclophosphamide, if their estimated glomerular filtration rate (eGFR) is at least 30 mL/min/1.73 m2. Or select MPAA plus a calcineurin inhibitor (CNI), such as voclosporin, tacrolimus, or cyclosporine, as long as patients’ eGFR exceeds 45 mL/min/1.73 m2.
With respect to practice points, when deciding between belimumab and a CNI, consider a CNI in patients with good kidney function who have heavy proteinuria due to podocyte injury because CNIs improve podocyte structure and function. Consider belimumab for patients with advanced chronic kidney disease (CKD) or those at high risk of LN flare.
For steroid sparing, using a limited number of intravenous methylprednisolone pulses at the start of treatment may allow reduced dosing and faster tapering of glucocorticoids.
Immunosuppressive management of pure class 5 membranous LN still needs to be clearly defined via dedicated randomized controlled trials. Patients with class 5 LN and nephrotic-range proteinuria may be treated with a glucocorticoid plus MPAA, CNI, or cyclophosphamide.
To reduce the risks for CKD progression, the guideline discussed blood pressure control including renin-angiotensin-aldosterone system blockade, LN flare prevention, and nephrotoxin avoidance. This section will likely expand in the future with incorporation of sodium-glucose cotransporter-2 inhibitors, endothelin-A receptor blockers, and other new agents for CKD as well as LN.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Rovin BH, Ayoub IM, Chan TM, et al. Executive summary of the KDIGO 2024 clinical practice guideline for the management of lupus nephritis. Kidney Int. 2024 Jan;105(1):31-34. doi:10.1016/j.kint.2023.09.001
Kidney Disease: Improving Global Outcomes (KDIGO) lupus nephritis work group. KDIGO 2024 Clinical practice guideline for the management of lupus nephritis. Kidney Int. 2024 Jan;105(1S):S1-S69. doi:10.1016/j.kint.2023.09.002
KDIGO announces publication of 2024 lupus nephritis guideline. News release. KDIGO; January 3, 2024.