Lupus Nephritis (LN)

Lupus nephritis (LN) most often begins within five years after the initial diagnosis of SLE. While LN symptoms may not be noticeable in its early stages, others may experience more pronounced symptoms of swelling.
Initial symptoms may include:

• Weight gain
• Unexplained swelling in the feet, ankles, legs, hands, and/or eyelids (swelling may become worse as the day progresses)
• Blood in the urine
• Foamy appearance of urine
• Increased urination (especially at night)
• Elevated blood pressure

Symptoms of LN will increase during a SLE flare and may require additional treatment strategies to control the flare.3 Flares are when patients experience a noticeable worsening of their SLE symptoms either due to uncontrolled disease activity or due to exposures to triggers (e.g. UV rays, certain medications, infection, injury, stress).

There are three commonly used tests to diagnose lupus nephritis: urine test, blood tests, and kidney biopsy. Significant kidney damage can be present before receiving a diagnosis, so getting tested is important to uncover any problems with how the kidneys are functioning.

1. Urine test:

• Checks for protein and/or blood in the urine as well as measures other markers that help to determine how efficiently the kidneys are functioning. For example: measures proteinuria and protein to creatinine ratio

2. Blood test:

• A blood test can help determine the degree of damage present in the kidneys as well as kidney function
• Blood tests measure serum creatinine (SCr), which is naturally removed from the blood by the kidneys. When the kidneys aren’t functioning appropriately, SCr accumulates in the blood. The level of SCr present in the blood is used to calculate how well your blood is filtered by the kidneys called “estimated glomerular filtration rate” (eGFR)

3. Kidney Biopsy:

• Shows the degree of inflammation or scarring present in the kidneys
• This involves taking one or more tiny samples of the kidney to be examined under a microscope
• Typically, an outpatient procedure and performed in a hospital

The primary goal of lupus nephritis (LN) treatment is to prevent chronic kidney disease, end-stage kidney disease and decrease associated morbidity and mortality.

Standard of care:

Initial treatment for active LN Class III or IV (+/- class V)

• Optimal kidney protective measures with: angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARBs) and hydroxychloroquine PLUS
• Glucocorticoids given intravenously (IV) then changed to orally. PLUS either: Mycophenolate mofetil (MMF) OR IV cyclophosphamide. OR alternatively, MMF plus a calcineurin inhibitor (CNI). CNI medications in LN include: voclosporin, tacrolimus, cyclosporin

Subsequent Treatment for LN Class III or IV (+/- Class V)

• MMF or azathioprine (AZA), in addition to hydroxychloroquine and the lowest possible dose of oral corticosteroids
• In cases of disease progression, patients may be treated with rituximab, IVIG, leflunomide, or combination MMF + Calcineurin inhibitor (CNI)

*Above treatment options are subject to change based on allergies, clinical presentation, and preferences.

A best-in-class orally administered CNI, voclosporin, can be used to stabilize the specialized cells in the kidney (known as podocytes), reduce adverse effects associated with chronic high-dose steroids, and it does not require blood level monitoring like other CNI’s in its class.