1. Nat. Rev. Nephrol. doi:10.1038/nrneph.2017.85
Figure 4 Proposed treatment algorithm for various pathological subtypes of lupus nephritis
Figure 4 | Proposed treatment algorithm for various pathological subtypes of lupus nephritis. We propose that the choice of treatment should depend on the pathological class of lupus nephritis as defined by the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification system, and the presence of additional pathogenic subtypes described in this Review. The treatment of ISN/RPS class I–VI lupus nephritis should follow basic therapeutic strategies according to the three major guidelines1,2,3. For the treatment of the additional subtypes based on the various pathogenesis, including crescentic lupus nephritis, podocyte injury, renal vascular lesions and tubulointerstitial lesions, a series of therapeutic intervention recommendations are proposed. For patients with crescentic lupus nephritis (which we define as the presence of crescents in ≥50% of glomeruli), we recommend first treating with plasma exchange (PE) and methlyprednisolone pulse (MP), combined with cyclophosphamide or rituximab. Additional treatment options that require further investigation include anti-complement agents (CCX-168 and eculizumab) and the CD80 inhibitor abatacept. Patients with severe tubulointerstitial lesions might be treated with rituximab or abatacept, although quality clinical trials are lacking. For patients with renal vascular changes, especially those with thrombotic microangiopathy (TMA), we suggest PE and MP as the first choice therapy. Eculizumab or recombinant thrombomodulin might also have potential but require further exploration. Rituximab or abatacept might have a role in the treatment of patients with prominent podocyte injury but further evidence of efficacy is required. In particular, the Kidney Disease: Improving Global Outcome guideline suggests that steroids and calcineurin inhibitors (CNIs) should be used in lupus podocytopathy2. Abs, antibodies; AZA, azathioprine; CYC, cyclophosphamide; GN, glomerulonephritis; H, corticosteroids; MMF, mycophenolate mofetil.
Yu, F. et al. (2017) Redefining lupus nephritis: clinical implications of pathophysiologic subtypes
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