Discussion on latest management of lupus nephritis
(Part 6)
In this week’s column, we will be continuing our discussion on the latest management techniques for lupus nephritis (LN).
We have seen that the recent studies that suggest the risk of end-stage kidney disease (ESKD) in LN have decreased to less than 10% in 15 years. However, some patients may progress towards irreversible kidney damage, which is related to increased risks of morbidity or mortality.
If a patient is on kidney replacement therapy, usually quiescent course and flares (both renal and extra-renal) may occur but no longer as frequent as before.
Among the kidney replacement modalities, hemodialysis, and continuous peritoneal dialysis are accompanied by the same patient survival rates based on comparative retrospective studies.
In the contest, kidney transplant is linked with a higher 10-year patient survival rate; as the data from the United States, Renal Data System show 70% reduced mortality among LN-ESKD patients who have undergone kidney transplantation compared with non-transplanted patients.
There is a special focus on the preference of transplantation over other kidney replacement options and should be given more consideration when extra-lupus is clinically (and ideally, serologically) inactive for at least half a year.
Presently, only a small portion of patients may undergo pre-emptive transplantation, although this strategy has been the favored outcome (10-year patient survival rates 94% vs 76% and 42%, for peritoneal dialysis and hemodialysis, respectively).
Transplantation is something that should be done as soon as possible and maybe safely done in the presence of isolated serological activity. The recurrence of LN in transplanted kidneys is rarely significant, at least, clinically.
Patients with transplanted kidneys and with LN are exposed to a higher risk of opportunistic infections due to the previous medicine or drug exposures.
Antiphospholipid syndrome and LN Antiohospholipid syndrome-associated nephropathy represents rate yet different type of antiphospolipidaantibodies (aPL)-induced vascular nephropathy.
While it is considered as a hallmark of antiphospholipid syndrome-associated nephropathy, thrombotic microangiopathy (TMA) is not pathognomonic, because of similar lesions that are found in the thrombotic thrombocytopenic purpura/hemolytic uraemic syndrome, malignant hypertension complement-mediated TMA.
There are no known controlled studies to guide the treatment of antiphospholipid syndrome-associated nephropathy.
Antiplatelet agents or anticoagulants (if the criteria for aPL syndrome are fulfilled) are allowed in addition to hydrocholoroqune (HCQ). Renin-angiotensin-aldosterone system blockade may delay the progression of the disease.
Next week we will discuss the management of LN during pregnancy and also the management of pediatric LN.