Chapter

The treatment of severe proliferative lupus nephritis

Richard J. Glassock

in Lupus Nephritis

Second edition

Published on behalf of Oxford University Press

Published in print November 2010 | ISBN: 9780199568055
Published online November 2012 | e-ISBN: 9780191753374 | DOI: http://dx.doi.org/10.1093/med/9780199568055.003.0012

Series: Oxford Clinical Nephrology Series

The treatment of severe proliferative lupus nephritis

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In a chapter entitled “Natural history and treatment of lupus nephritis” published in the first edition (1999) of this book, Edmund Lewis stated that “lupus nephritis, its clinical course, prognosis and optimal therapy are subjects which are plagued by a surfeit of authoritative opinion, however there is limited scientifically valid information.” More than a decade later, the plague of “authoritative opinion” has not lessened, but the availability of “scientifically valid information” has certainly increased, largely thorough the design and execution of expensive and time-consuming prospective, randomized, controlled clinical trials (RCT) involving the volunteerism of countless brave subjects suffering from lupus nephritis. If the magnitude of “scientifically valid information” has increased, as it has, why then are we still plagued by “a surfeit of authoritative opinions?” The answer to this daunting question lies in the vagaries of lupus nephritis itself—its unpredictability, its diversity, its pathogenetic heterogeneity—and in the inherent limitations of RCT, however well designed and executed, to address the critical questions posed by individual patients with lupus nephritis. A large gap exists between the body of scientific evidence and the achievement of a universal strategy for optimally effective and safe treatment of lupus nephritis. Much progress has been made in narrowing this gap, but much still needs to be done. Preliminary expert opinions and evidence-based guidance have been developed and more are anticipated. In many respects the future for treatment of lupus nephritis is bright, as we learn more about the intricate details of pathogenesis and design more targeted, “rational” approaches to treatment, while at the same time diminish the risk of adverse consequences of our therapy.

This chapter builds on the base developed by Dr. Lewis and his colleagues in the landmark 1999 contribution, and will focus primarily on new developments in the last decade. In addition, it will deal primarily with “severe,” proliferative lupus nephritis, as defined elsewhere in the book (see alsoChapter 6). The treatment of membranous lupus nephritis is covered in Chapter 7, lupus podocytopathy in Chapter 8 and thrombotic microangiopathy complicating lupus nephritis in Chapter 9. Milder forms of lupus nephritis, such as the mesangial and mild focal proliferative forms (Class I, II, and III <50%, see also Chapter 6), often respond to steroids alone and do not require aggressive therapy, unless they transform to more severe proliferative lupus nephritis. In keeping with the theme of this monograph and its predecessor, both “authoritative opinion” and “scientifically valid evidence” will be carefully and separately identified. It is hoped that a proper balance of evidence-based and opinion-based therapeutic strategies for severe lupus nephritis can be achieved.

Chapter.  17731 words. 

Subjects: Nephrology

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