This protocol targets patients with systemic lupus erythematosus presenting with active proliferative lupus nephritis whose glomerular filtration rate remains preserved — and in whom renal biopsy shows no cellular crescents, no fibrinoid necrosis, and no severe interstitial inflammation.
Management involves glucocorticoid pulses combined with an immunosuppressive anchor agent. The protocol also addresses when combination strategies with additional agents should be considered, and how therapy is structured for the maintenance phase. Full agent selection, sequencing, and maintenance planning are in the complete regimen.
DOI: 10.1136/ard-2023-224762
Patients with active proliferative lupus nephritis should receive low-dose (EuroLupus) intravenous cyclophosphamide (1a/A) or mycophenolate (1a/A) and glucocorticoids (pulses of intravenous methylprednisolone followed by lower oral doses); combination therapy with belimumab (either with cyclophosphamide or mycophenolate (1b/A)) or calcineurin inhibitors (especially voclosporin or tacrolimus, combined with mycophenolate, 1b/A) should be considered.
Following renal response, treatment of lupus nephritis should continue for at least 3 years; patients initially treated with mycophenolate alone or in combination with belimumab or a calcineurin inhibitor should remain on these drugs, whereas azathioprine or mycophenolate should replace cyclophosphamide for those initially treated with cyclophosphamide alone or in combination with belimumab.
Following the choice of initial treatment, renal response should be monitored according to the 2019 EULAR/ERA-EDTA targets (reduction in proteinuria ≥25% and 50% at 3 and 6 months, respectively, and below 500–700 mg/day at 12 months, all with GFR within 10% from baseline).
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