The ACR’s State-of-the-Art Clinical Symposium: Experts Discuss Jakinibs, Osteoarthritis, Membranous Lupus Nephritis

“Not all of this footwear is available,” Dr. Shakoor said. “I tell you this so that you have an idea about how to think of biomechanics. When your patients ask you about recommendations, … then maybe you’ll have at least some evidence” and could recommend a lighter, more flexible shoe, keeping in mind a patient’s possible foot conditions.

Glomerular Nephritis

Dr. Ramsey-Goldman

Rosalind Ramsey-Goldman, MD, DrPH, Solovy Arthritis Research Society Professor of Medicine at the Northwestern University Feinberg School of Medicine, said membranous lupus nephritis (MLN) is important for clinicians to watch for and treat. End-stage renal disease is all too common for these patients.

MLN is characterized by subepithelial immune deposits along peripheral capillary loops with glomerular capillary wall thickening, and podocytes on the outside of the glomerular basement membrane as the target of the autoimmune response.

If the podoctye is damaged, “it can alter the internal milieu,” Dr. Ramsey-Goldman said, with additional antigens and autoantibodies that can bring about progressive disease. So it’s important to stop the initial insult.

There are some differences between membranous and proliferative lupus nephritis—hypertension and certain serologic markers are more common in the proliferative type—but the similarities are such that a kidney biopsy is needed for a definitive diagnosis, Dr. Ramsey-Goldman said.

The ACR guidelines on LN treatment call for hydroxychloroquine for all patients with LN, along with blood pressure control, statins for hyperlipidemia, angiotensin inhibition for those with proteinuria of more than 0.5 gm per day, and counseling on contraception and pregnancy risks.

A meta-analysis published in 2011 found that the rate of either complete or partial response for steroids along with a nonsteroidal immunosuppressive treatment was 81%, but for steroid-only treatment, it was 60%.¹ “This would suggest that adding something to steroids would be helpful,” Dr. Ramsey-Goldman said.

Another study out of the National Institutes of Health casts doubt on this. Although prednisone plus intravenous Cytoxan, as well as prednisone plus cyclosporine, showed better remission rates after one year, patients in the Cytoxan group also were more likely to relapse, and “pretty quickly,” after that first year.² Dr. Ramsey-Goldman said this study is notable in that it is the only one with follow-up long enough to show relapse.

In a look at the most recent literature on LN, Dr. Ramsey-Goldman reviewed a 2015 study comparing tacrolimus and mycophenolate mofetil (MMF) as induction therapy. They both showed improvements over six months in urine/protein creatinine ratio, but without differences between the arms.³