Treatment of Lupus-Related Kidney Disease

Lupus Nephritis' treatment requires a thorough assessment of these options


We discussed in another article about how Systemic Lupus Erythematosus (SLE), or lupus as it is commonly known affects the kidney.  Kidney disease because of lupus is referred to as lupus nephritis.  Lupus nephritis can have various long-term outcomes, ranging from benign smouldering disease, to rapid progression towards complete kidney failure requiring dialysis or kidney transplantation in the worst case scenario.

 A kidney biopsy is often required to differentiate between the these prognostic possibilities.

Once clinical suspicions warrant it, and a kidney biopsy is done, your nephrologist and you will be faced with multiple treatment options that you should consider to minimize damage to the kidney and prevent decline towards kidney failure.  This article gives an overview about these options.  It is not meant to be a comprehensive one-stop decision making tool since that is usually a more complicated process which requires extensive discussion between you and your nephrologist.

Not every form of lupus nephritis will necessarily cause kidney failure

Traditionally, there are 6 subcategories of lupus nephritis (although we nephrologists keep debating about changing that!).  In other words, when lupus does involve the kidney, physicians will group it into one or more of 6 different diagnostic categories.

 Those categories have different prognostic implications and different approaches to treatment. 

Since lupus is an autoimmune disease, medications that suppress your immune system do have a role in treatment of severe forms of lupus nephritis.  However, these medications might not be needed for every form of lupus nephritis.

Hence we do have other "first-line" non-immunosuppressive drugs that most patients (regardless of the category of nephritis) should be on (with the option of adding the bigger gun immunosuppressive medications if needed).

Non-immunosuppressive medications: Renin Angiotensin Inhibitors

From the time of their discovery from snake venom, renin angiotensin inhibitors have changed the face of treatment of high blood pressure, heart failure, and kidney disease. They have a major role in treatment of lupus nephritis.  Since a lot of patients with lupus nephritis have abnormally high amount of protein loss in the urine (proteinuria), renin angiotensin inhibitors are very useful given their anti-proteinuric effects.  How this happens is hard to cover here in extensive detail, but one of the major effects is a reduction of pressure inside the kidneys' filter, or the intraglomerular pressure.  This should typically lead to reduction in the protein loss in the urine, and therefore improve the long-term outcome.

Lupus nephritis may cause other complications:

  • Severely high elevation in protein loss in the urine, can lead to an entity called nephrotic syndrome.  This can sometimes make your cholesterol levels abnormally high.  Therefore, another type of non-immunosuppressive medications called statins might be advisable.
  • Finally, lupus nephritis patients with nephrotic syndrome could be at a higher risk of forming a blood clot and some may benefit from blood thinners.

Immunosuppressive medications: The Big Guns

If a kidney biopsy reveals severe and active form of lupus nephritis (sometimes referred to as proliferative lupus nephritis) medications that suppress immune mediated damage to the kidney could become necessary.  Some of these are the same medications that are used to prevent rejection in patients who have received a kidney transplant.

The most commonly known immunosuppressive medications are in fact steroids (an example being prednisone).  These will often need to be combined into complicated regimens with other medications that most people would not have heard of.  These include agents like mycophenolate mofetil (or CellCept),  cyclophosphamide, cyclosporine, etc. 

If all this fails?

In the worse case scenario, the patient might not see any  improvement with the above medications, or be in a situation where the kidney is already irreparably damaged/scarred by the time the disease is diagnosed (in which case it would really be futile to even consider these medications). In this setting, arrangements for renal replacement therapy, either with dialysis or kidney transplantation will probably need to be made.  Lupus nephritis should not necessarily stop anybody from getting a kidney transplant, but most transplant programs will require that the disease be dormant before considering transplantation.

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