Management of Adult Patients with Lupus Nephritis: Therapeutic Algorithm Based on the Current Treatment Guidelines

Abstract

Lupus nephritis (LN) is one of the most significant manifestations of systemic lupus erythematosus (SLE) affecting approximately 35–40% of patients in large cohort studies. It is usually diagnosed in the early phases of the disease; among those with LN, approximately 80% are diagnosed at or shortly after disease onset. LN is characterized by histological and clinical heterogeneity and substantially affects survival. A meta-analysis of 18,309 LN patients reported a 10-year risk for the development of end-stage kidney disease (ESKD) of nearly 17% overall and 33% among those with LN class IV (diffuse proliferative form). Early detection and timely management are essential for optimizing outcomes. Given that LN patients are often asymptomatic, it is recommended that all lupus patients, particularly early in the disease course, undergo routine screening every 3–6 months. This includes assessment of proteinuria with urinary protein‑ or albumin‑to‑creatinine ratio (and 24 hour urine protein if indicated), urinary sediment and serum creatinine, regardless of disease activity. If abnormal findings that cannot be explained by alternative causes are detected (proteinuria ≥500 mg/day, active urinary sediment with acanthocytes ≥5% or red blood cell casts or white blood cell casts, increased serum creatinine) a renal biopsy should be performed, as it remains the gold standard for confirming the diagnosis, management planning, and informing the prognosis.

Herein, we present a step-by step approach to the current management of adult LN as recommended by the 2024 American College of Rheumatology (ACR), the 2025 updated European Alliance of Associations for Rheumatology (EULAR), as well as the 2024 KDIGO (Kidney Disease: Improving Global Outcomes) guidelines. New treatment options that will be available in the near future are also discussed briefly.

Should emphasize that the focus is on adult LN approach. The ACR guidelines also discuss children, so I think it should be acknowledged that the focus here is for adults.

If the author is not going to talk about the KDIGO guidelines (which are more recent than the EULAR guidelines), they should be at least acknowledged early on and perhaps just mention some of the differences between ACR/KDIGO as readers it’s been a point of debate and discussion at multiple lupus meetings.