Therapy of resistant or relapsing diffuse or focal proliferative lupus nephritis
- Ronald J Falk, MD
Ronald J Falk, MD
- Allan Brewster Distinguished Professor of Medicine
- Chair, Department of Medicine
- Director, UNC Kidney Center
- Director, Center for Transplant Care
- University of North Carolina-Chapel Hill
- Maria Dall'Era, MD
Maria Dall'Era, MD
- Associate Professor of Medicine
- University of California, San Francisco
- Gerald B Appel, MD
Gerald B Appel, MD
- Section Editor — Glomerular Diseases
- Professor of Medicine
- Columbia University College of Physicians and Surgeons
- Section Editors
- Richard J Glassock, MD, MACP
Richard J Glassock, MD, MACP
- Editor-in-Chief — Nephrology
- Section Editor — Glomerular Diseases
- Emeritus Professor
- The David Geffen School of Medicine at UCLA
- Brad H Rovin, MD
Brad H Rovin, MD
- Section Editor — Glomerular Diseases
- Professor of Medicine and Pathology
- The Ohio State University College of Medicine
Treatment of lupus nephritis (LN) varies with the type of disease (morphologic class) that is present. However, no single regimen is regarded as optimal for all patients with LN, and treatment must be individualized. Combined immunosuppressive therapy is typically indicated in patients with diffuse and focal proliferative LN and in many patients with lupus membranous nephropathy. (See "Diagnosis and classification of renal disease in systemic lupus erythematosus" and "Clinical features and therapy of lupus membranous nephropathy".)
Some patients are truly resistant to initial immunosuppressive treatments despite full compliance with the prescribed regimen. By contrast, a greater number of patients are perceived to have resistant LN. The rate of true resistance varies with the ancestry of the patient, whereas the rate of perceived resistance is impacted by the extent to which the patient complies with the prescribed regimen (ie, noncompliance) and the adequacy of the prescribed regimen compared with the standard of care (ie, inadequate dosing). Perceived resistance may also depend in part upon the criteria that are used to define response.
Relapsing LN is substantially more common than resistant disease. Nearly one-half of patients with proliferative LN who initially achieve a complete response on immunosuppressive therapy will have a relapse (also called renal flare) following reduction in or cessation of immunosuppression.
The treatment of resistant and relapsing LN will be reviewed here. The treatment of proliferative LN and lupus membranous nephropathy, as well as issues related to end-stage LN, are presented separately. (See "Therapy of diffuse or focal proliferative lupus nephritis" and "Clinical features and therapy of lupus membranous nephropathy" and "End-stage renal disease due to lupus nephritis".)
DISEASE RESISTANT TO INITIAL IMMUNOSUPPRESSIVE THERAPY
Patients who fail to achieve a response to initial immunosuppressive therapy are defined as having resistant disease. As noted above, true resistant disease is uncommon. Perceived resistance, which is more common, is often due to incomplete compliance or noncompliance with the prescribed immunosuppressive regimen or to inadequacy of the prescribed regimen.
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- DISEASE RESISTANT TO INITIAL IMMUNOSUPPRESSIVE THERAPY
- Definition of complete response
- Treatment of resistant disease
- - Cyclophosphamide resistance
- - MMF resistance
- - Rituximab for cyclophosphamide and MMF resistance
- - MMF plus tacrolimus
- - Belimumab
- RELAPSING DISEASE
- Definition and clinical recognition
- - Monitoring
- Treatment of relapsing disease
- - Mild relapse
- - Moderate to severe relapse
- DIFFUSE PROLIFERATIVE LN PLUS LUPUS MEMBRANOUS NEPHROPATHY
- SUMMARY AND RECOMMENDATIONS
- Resistant disease
- Relapsing disease