The ACR Releases New Lupus Nephritis Guideline

Treatment Duration & Monitoring

Lupus nephritis requires extended treatment to decrease the risk of flares. Thus, it is conditionally recommended that patients who have achieved a complete renal response extend their treatment period to at least three to five years, whether they were receiving triple or dual therapy.

“Repeat kidney biopsy shows that immunologic activity persists for several years and withdrawal of immunosuppression predisposes patients to lupus flare,” Dr. Sammaritano said.

The guideline includes two strong recommendations for monitoring. For patients whose renal disease has not completely responded to therapy, proteinuria should be quantified at least every three months. In patients who have shown a sustained and complete response, proteinuria should still be monitored, but this timeframe can be stretched to every three to six months.

Implementation

The guideline also contains additional recommendations and good practice statements on other aspects of care, including adjunctive treatments, refractory disease and renal replacement therapy.

Dr. Sammaritano recognized that some patients face barriers in access to newer medications.

“We are mindful of [these barriers], and available traditional therapies should absolutely be used if recommended medications are not available,” she said. “But we do hope to encourage rheumatologists to be somewhat more aggressive in their treatment with the hope that, overall, this new generation of patients who are battling lupus nephritis will have better outcomes than we have seen in the past.”

Ruth Jessen Hickman, MD, a graduate of the Indiana University School of Medicine, is a medical and science writer in Bloomington, Ind.

References

   
1. Sammaritano L, Askanase A, Bermas BL, et al. 2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis. Arthritis Rheumatol. 2025. Online ahead of print.
2. Hahn BH, McMahon MA, Wilkinson A, et al. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken). 2012 Jun;64(6):797–808.
3. Parodis I, Tamirou F, Houssiau FA. Prediction of prognosis and renal outcome in lupus nephritis. Lupus Sci Med. 2020 Feb 18;7(1):e000389.
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5. Rovin BH, Teng YKO, Ginzler EM, et al. Efficacy and safety of voclosporin versus placebo for lupus nephritis (AURORA 1): A double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet. 2021 May 29;397(10289):2070–2080.
6. Houssiau FA, Vasconcelos C, D’Cruz D, et al. Immunosuppressive therapy in lupus nephritis: The Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum. 2002 Aug;46(8):2121–2131. doi:10.1002/art.10461
7. Figueroa-Parra G, Cuéllar-Gutiérrez MC, González-Treviño M, et al. Impact of glucocorticoid dose on complete response, serious infections, and mortality during the initial therapy of lupus nephritis: A systematic review and meta-analysis of the control arms of randomized controlled trials. Arthritis Rheumatol. 2024 Sep;76(9):1408–1418.