EULAR rheumatology open · 2025
Management of systemic lupus erythematosus with kidney involvement: systematic literature review to inform the 2025 update of EULAR recommendations.
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Kostopoulou Myrto, Bertsias George, Scire Carlo Alberto, Boumpas Dimitrios T, Fanouriakis Antonis
Аннотация
OBJECTIVES: To identify, appraise, and synthesise current evidence regarding the management of systemic lupus erythematosus (SLE) with kidney involvement towards informing the 2025 update of the European Alliance of Associations for Rheumatology (EULAR) recommendations.
METHODS: The Task Force formulated 11 research questions grouped into 6 distinct sections, namely indications of diagnostic kidney biopsy; treatment targets; efficacy and safety of immune treatments in lupus nephritis (LN); efficacy and safety of nonimmune treatments; treatment duration; and indications for repeat kidney biopsy. A dedicated systematic literature review (SLR) was performed for each section. SLRs were performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials from January 2019 to March 2024.
RESULTS: Patients with SLE with low-grade proteinuria (<500-1000 mg/d) and/or haematuria may have histologically active disease, based on evidence of moderate quality. Observational studies of good quality have demonstrated an association between complete or partial renal response within the first 6 to 12 months and long-term kidney survival. A combination of 2 immunosuppressive agents, such as belimumab with mycophenolate mofetil (MMF)/cyclophosphamide, voclosporin with MMF, or obinutuzumab with MMF, is associated with higher response rates, based on high-quality randomised controlled trials (RCTs). Discontinuation of treatment has been linked with an increased risk of relapse, as evidenced by 3 RCTs with substantial heterogeneity.
CONCLUSIONS: High-quality RCTs indicate a benefit from combination treatments compared with previous standard-of-care in LN. Patients who respond within the first year of treatment tend to have better long-term outcomes. Kidney biopsy is essential for diagnosis, but the role of repeat biopsy awaits confirmation from higher-quality studies.
METHODS: The Task Force formulated 11 research questions grouped into 6 distinct sections, namely indications of diagnostic kidney biopsy; treatment targets; efficacy and safety of immune treatments in lupus nephritis (LN); efficacy and safety of nonimmune treatments; treatment duration; and indications for repeat kidney biopsy. A dedicated systematic literature review (SLR) was performed for each section. SLRs were performed in PubMed, Embase, and the Cochrane Central Register of Controlled Trials from January 2019 to March 2024.
RESULTS: Patients with SLE with low-grade proteinuria (<500-1000 mg/d) and/or haematuria may have histologically active disease, based on evidence of moderate quality. Observational studies of good quality have demonstrated an association between complete or partial renal response within the first 6 to 12 months and long-term kidney survival. A combination of 2 immunosuppressive agents, such as belimumab with mycophenolate mofetil (MMF)/cyclophosphamide, voclosporin with MMF, or obinutuzumab with MMF, is associated with higher response rates, based on high-quality randomised controlled trials (RCTs). Discontinuation of treatment has been linked with an increased risk of relapse, as evidenced by 3 RCTs with substantial heterogeneity.
CONCLUSIONS: High-quality RCTs indicate a benefit from combination treatments compared with previous standard-of-care in LN. Patients who respond within the first year of treatment tend to have better long-term outcomes. Kidney biopsy is essential for diagnosis, but the role of repeat biopsy awaits confirmation from higher-quality studies.