What Is the Current Recommended Treatment for Lupus Nephritis?

Medical Author: William C. Shiel Jr., MD, FACP, FACR
Medical Editor: Leslie J. Schoenfield, MD, PhD

Lupus nephritis is kidney disease that is caused by lupus. To start, it must be understood that there are many forms of kidney disease that are referred to as lupus nephritis. Each form is distinguished by characteristic patterns of abnormalities as defined by a kidney biopsy. (A biopsy is the removal of a sample of tissue for microscopic examination.) Typically, the findings on a kidney biopsy of a lupus patient are classified according to the appearance of the tissue and immune abnormalities seen under the microscope.

In addition to the numerous unique forms of lupus kidney disease, other types of kidney diseases that are not from lupus can sometimes occur in a patient with lupus. While treatment for lupus nephritis can sometimes be initiated without a kidney biopsy, more often, a biopsy is done before starting treatment. Thus, when the blood tests and the overall state of the lupus disease so require, the biopsy can define the cause of the kidney disease when it is in question. The biopsy can also guide treatment when it demonstrates the presence of such severe kidney damage that a favorable response to potentially toxic medications is unlikely.

Any particular form of lupus nephritis has a variety of treatments available that are effective. Moreover, the treatment for individual patients with lupus nephritis depends not only on their own particular form of kidney disease, but also on the manner in which lupus is affecting other areas of their body, their overall health, and their personal wishes. Also, medical control of conditions that could further injure the kidneys, such as elevated blood pressure and medication-induced kidney toxicity, is essential.

In general, lupus nephritis is a result of inflammation in the kidneys that is associated with an overactive immune (defense) system. As a consequence, antibodies against the patient's own tissues (auto-antibodies) form antibody-tissue (antibody-antigen) unions (complexes) that in turn deposit in the kidney and initiate a destructive inflammatory reaction. In fact, very often, the severity of the kidney disease parallels the severity of the immune abnormalities that can be measured in the blood of patients with lupus (such as DNA antibody, complement levels, etc.). Accordingly, treatment usually involves medications that reduce inflammation and suppress the immune system. When lupus nephritis leads to kidney failure, however, kidney dialysis or transplantation is necessary to sustain life.

Corticosteroids, such as prednisone and prednisolone, are accepted as the initial treatment for lupus nephritis. The steroids may be given by mouth or intravenously. Also, high dose corticosteroids (methylprednisolone) that are given in single, large doses (pulses) intravenously for three consecutive days are also a useful initial treatment for lupus nephritis, which is then followed by corticosteroids by mouth. The immune suppression medications that are used to treat lupus nephritis include azathioprine (Imuran) and cyclophosphamide (Cytoxan), both of which can be given by mouth. Cyclophosphamide is also given as an intravenous, single large dose (pulse) in certain situations. These pulses are continued monthly for six months and every three months thereafter. Recently, the immunosuppressant drug mycophenolate mofetil (Cellcept) has been used successfully to treat lupus kidney disease and seems to represent another option.

Other treatments that are used for lupus nephritis, but are still unproven or controversial, include plasmapheresis, intravenous immunoglobulin infusions, and fish oils containing omega-3 fatty acids. Plasmapheresis is a procedure in which the blood is filtered through a special machine to separate the plasma, which is the liquid portion of the blood, from the cells of the blood. The plasma is removed and replaced, typically with another solution such as saline or albumin. Intravenous immunoglobulin is a sterile solution of concentrated antibodies extracted from healthy people that is given straight into a vein. The immunoglobulin is used to treat disorders of the immune system or to boost the immune response to serious illness. Omega-3 fatty acids have been shown to reduce inflammation in the kidneys of mice with a lupus-like illness.