Bose, Silverman, and Bargman provide an excellent summary of common mistakes and misconceptions about the treatment of lupus nephritis. Their list of the 10 most common mistakes serves as an excellent treatment guide for both the novice and experienced clinician, and nicely summarizes the state of both current and historical knowledge regarding successful (and failed) treatment. Their list of mistakes can be divided into choices of drug therapy, awareness of toxicity and side effects, and patient-specific concerns.
From a drug treatment perspective, they remind the reader that intravenous cyclophosphamide is no longer the “gold standard” treatment for lupus nephritis and that other regimens provide similar durable remission rates with improved side effect and toxicity profile. They also remind the clinician not to be so distracted by the choice of immune suppression that the corticosteroid regimen is neglected. Landmark trials of treatment regimens for lupus nephritis have all included high dose corticosteroids. In fact, the point of differentiation between many of the various treatments has not been the induction of a successful remission, but the prevention of long term relapse. They also remind the reader that anti-malarials should not be neglected in the treatment regimen as they have benefit in treating both the systemic and kidney-specific effects of lupus.
With regard to toxicity, they caution not to over-treat certain types of lupus nephritis, and to dose adjust appropriately in cases where kidney function is impaired. Excessive reliance on urinary sediment findings as a marker of response to therapy can also be problematic and potentially lead to over-treatment. They also warn against unnecessary kidney biopsies when management will not be altered by the results. Neglecting prophylaxis and monitoring for opportunistic infections in patients on immune suppressive therapy can be very dangerous for the patient and should not be ignored.
Lastly, patient-specific concerns are essential to the treatment regimen as well. Patient non-adherence, especially given the side effect profiles of some of the agents, is an important cause of treatment failure, and addressing non-adherence will be far more successful than trying to change the drug regimen. Fertility and pregnancy also need to be taken into account for young women undergoing treatment for lupus nephritis.
While some elements in this list of mistakes are likely to generate some discussion among experienced clinicians, the entire list serves as an excellent reminder of elements that are important for a successful treatment of lupus nephritis.
John W. O’Bell, M.D.
Assistant Professor of Medicine, Division of Kidney Disease and Hypertension, The Warren Alpert Medical School of Brown University