2. Algorithms
Treatment of lupus nephritis in adult patients
Sundeep Upadhyaya
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India
Abstract
This set of management principles which is based on personal
practice and refers to the American College of Rheumatology
Guidelines1
and the European league against Rheumatology
recommendations2
are particularly suited to India and the
Indian Ethnic population. It also takes into account the pre-
vailing principles of treatment widely accepted among the
rheumatologists of the Indian subcontinent.
The ISN/RPS classification of lupus nephritis (2003)3
defines
nephritis in the clinical setting of a patient with SLE, who has
proteinuria >500 mg per day or 3þ proteinuria by dipsticks
and/or active urinary sediment. This classification broadly
lists classes of lupus nephritis from Class I to Class VI. This
algorithm outlines the treatment plan for Class III/IV and
Class V lupus nephritis. Some notable points e Cyclo-
phosphamide (CYC) in the Indian Subcontinent is usually
initiated at a dose of 750 mg/m,2
and final doses are adjusted
to a nadir of leucocyte counts at (2 weeks e 3000e4000/mL)
follow up. The “EUROLUPUS” regime (500 mg CYC every
fortnight  3 months) for induction treatment is valid mostly
for certain white European ethnic groups. Not mentioned in
this algorithm are I.V. boluses of Methyl Prednisolone com-
monly used in India and the world over for induction (based
on expert opinion only).
Class I/II lupus nephritis needs no specific treatment and
for Class VI nephritis, renal replacement therapy is the pre-
ferred mode of treatment all over the world including India.
One exception would be Class II nephritis with >1 g/day pro-
teinuria, where according to the EULAR/ERA-EDTA recom-
mendations2
Steroids and AZA may be used. Both the ACR
guidelines and Rheumatology practitioners all over the world
recommend treatment of all their SLE patients with hydrox-
ychloroquine and treat hypertension to a target of 130/80;
use ACE inhibitors/ARBs for any proteinuria >500 mg per day;
and statins to treat LDL cholesterol >100 mg per day. As for
MMF (Mycophenolate Mofetil) doses, the Asian/Indian popu-
lation can make do with 2 g per day for induction instead of 3 g
per day, except when there are significantly more crescents
seen on histopathology and there is significant activity (as
deemed by the histopathologist).
For younger female patients, where MMF cannot be used
(severe disease, extensive crescents on histopathology or
have failed MMF therapy) cyclophosphamide therapy can be
and is very frequently used along with luprolide to prevent
gonadal toxicity. As for pregnant patients, in my personal
practice (and also as spelled out in the ACR lupus guidelines),
the services of an obstetricianegynaecologist, who has
experience with treatment of lupus patients should be
employed. Adjunctive therapy like Calcium, Vitamin D sup-
plements, & Iron and folic acid therapy are also mandatory.
The following is the accepted norm for pregnant lupus
nephritis patients: (a) no activity on histopathology, no spe-
cific therapy; (b) for minimal mild activity, hydroxy-
chloroquine 200e400 mg per day and (c) for significant
nephritis, glucocorticoids (GC) (þ), Azathioprine (AZA). Some
other notable highlights of my personal practice are the def-
initions of “improved/not improved” in the algorithm (these
are loosely based on the work of several Indian investigators
and the ACR guidelines). Also of note, is the omission of
Azathioprine for induction; it is now the second agent of
choice after MMF for maintenance therapy1,2
(usually 3 years).
E-mail address: sundeepupadhyaya@hotmail.com.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 8 5 e8 6
0976-0016/$ e see front matter
http://dx.doi.org/10.1016/j.apme.2013.01.010
3. r e f e r e n c e s
1. Hahn BH, McMahon MA, Wilkinson A, et al. American
College of Rheumatology guidelines for screening,
treatment and management of lupus nephritis.
2012;64:797e808.
2. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European
League Against Rheumatism and European Renal Association-
European Dialysis and Transplant Association (EULAR/ERA-
EDTA) recommendations for the management of adult and
paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771e1782.
3. Weening JJ, D’Agati VD, Schwartz MM, et al. The classification
of glomerulonephritis in systemic lupus erythematosus
revisited. J Am Soc Nephrol. 2004;15:241e250.
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