American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis

Bevra H. Hahn(University of California, Los Angeles), Maureen McMahon(University of California, Los Angeles), Alan Wilkinson, William D. Wallace(University of California, Los Angeles), David Daikh(University of California, San Francisco), John FitzGerald(University of California, Los Angeles), George Karpouzas(University of California, Los Angeles), Joan T. Merrill(Oklahoma Medical Research Foundation), Daniel J. Wallace(University of California, Los Angeles), Jinoos Yazdany(University of California, San Francisco), Rosalind Ramsey‐Goldman(Northwestern University), Karandeep Singh(University of California, Los Angeles), Mazdak A. Khalighi(University of California, Los Angeles), Soo‐In Choi(University of California, Los Angeles), Maneesh Gogia(University of California, Los Angeles), Suzanne Kafaja(University of California, Los Angeles), Mohammad Kamgar(University of California, Los Angeles), Christine Lau(University of California, Los Angeles), W. J. Martin(University of California, Los Angeles), Sefali Parikh(University of California, Los Angeles), Justin Peng(University of California, Los Angeles), Anjay Rastogi(University of California, Los Angeles), Weiling Chen(University of California, Los Angeles), Jennifer M. Grossman(University of California, Los Angeles)
Arthritis Care & Research
May 3, 2012
10.1002/acr.21664
Cited by 1,482

Abstract

In the United States, approximately 35% of adults with Systemic Lupus Erythematosus (SLE) have clinical evidence of nephritis at the time of diagnosis; with an estimated total of 50–60% developing nephritis during the first 10 years of disease [1–4]. The prevalence of nephritis is significantly higher in African Americans and Hispanics than in Caucasians, and is higher in men than in women. Renal damage is more likely to develop in non-Caucasian groups [2–4]. Overall survival in patients with SLE is approximately 95% at 5 years after diagnosis and 92% at 10 years [5, 6]. The presence of lupus nephritis significantly reduces survival, to approximately 88% at 10 years, with even lower survival in African Americans [5, 6]. The American College of Rheumatology (ACR) last published guidelines for management of systemic lupus erythematosus (SLE) in 1999 [7]. That publication was designed primarily for education of primary care physicians and recommended therapeutic and management approaches for many manifestations of SLE. Recommendations for management of lupus nephritis (LN) consisted of pulse glucocorticoids followed by high dose daily glucocorticoids in addition to an immunosuppressive medication, with cyclophosphamide viewed as the most effective immunosuppressive medication for diffuse proliferative glomerulonephritis. Mycophenolate mofetil was not yet in use for lupus nephritis and was not mentioned. Since that time, many clinical trials of glucocorticoids-plus-immunosuppressive interventions have been published, some of which are high quality prospective trials, and some not only prospective but also randomized. Thus, the ACR determined that a new set of management recommendations was in order. A combination of extensive literature review and the opinions of highly qualified experts, including rheumatologists, nephrologists and pathologists, has been used to reach the recommendations. The management strategies discussed here apply to lupus nephritis in adults, particularly to those receiving care in the United States of America, and include interventions that were available in the United States as of April 2011. While these recommendations were developed using rigorous methodology, guidelines do have inherent limitations in informing individual patient care; hence the selection of the term “recommendations.” While they should not supplant clinical judgment or limit clinical judgment, they do provide expert advice to the practicing physician managing patients with lupus nephritis.

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