2019 Update of the Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA–EDTA) recommendations for the management of lupus nephritis

Fanouriakis, Antonis; Kostopoulou, Myrto; Cheema, Kim; Anders, Hans Joachim; Aringer, Martin; Bajema, Ingeborg M.; Boletis, John; Frangou, Eleni; Houssiau, Frédéric; Hollis, Jane; Karras, A.; Marchiori, Francesca; Marks, Stephen D.; Moroni, Gabriella; Mosca, Marta; Parodis, Ioannis; Praga, Manuel; Schneider, Matthias; Smolen, Josef S; Tesař, Vladimı́r; Trachana, Maria; Vollenhoven, Ronald F. van; Voskuyl, Alexandre E.; Teng, Y K Onno; Leew, Bernadette Van; Βertsias, George; Jayne, David; Boumpas, Dimitrios T.

doi:10.1136/annrheumdis-2020-216924

Cited by 569 publications

(574 citation statements)

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“…2 Since then, a number of randomised controlled trials (RCTs) have been conducted and meta-analyses of different treatments have been published, while a number of issues regarding optimal monitoring of LN, duration of immunosuppressive treatment and management of end-stage kidney disease (ESKD) are still a matter of debate. To this end, an update of the 2012 recommendations was recently published, 3 with the participation of a multidisciplinary Task Force.…”

Section: Introductionmentioning

confidence: 99%

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

et al. 2020

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ObjectivesTo analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations.MethodsAccording to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012.ResultsWe identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b).ConclusionsThere is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.

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Section: Introductionmentioning

confidence: 99%

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

et al. 2020

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“…It is recommended that HCQ dose should be reduced in ESRD due to decreased renal excretion in these patients and a concern for potential toxicity [35][36]. In this relatively small sample of SLE ESRD patients, two patients had a documented HCQ related toxicity despite dose adjustment underscoring the need for further studies to examine the relationship of blood HCQ level, drug e cacy, and toxicity in SLE patients with ESRD.…”

Section: Discussionmentioning

confidence: 94%

Systemic Lupus Erythematosus Activity and Hydroxychloroquine Use Before and After End Stage Renal Disease

Guerrero

Jimenez

Dobrowolski

et al. 2020

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Background: SLE manifestations after ESRD may be underdiagnosed and undertreated, contributing to increased morbidity and mortality. Whether specific symptoms persist after ESRD or a shift towards new manifestations occurs has not been studied. In addition, hydroxychloroquine (HCQ) prescribing patterns post-ESRD have not been described. The objective of this study was to assess lupus activity and HCQ prescribing before and after ESRD development. Knowledge gained from this study may aid in the identification of SLE manifestations and improve medication management post-ESRD. Methods: We performed a retrospective cohort study of SLE patients with incident ESRD between 2010 and 2017. SLE-related symptoms, serologic markers of disease activity, and medication use were collected from medical records before and after ESRD development. Results: Fifty-nine patients were included in the study. Twenty-five (43%) patients had at least one clinical (non-renal) SLE manifestation documented within 12 months before ESRD. Of them, 11/25 (44%) continued to experience lupus symptoms post-ESRD; 9 patients without clinical or serological activity pre-ESRD developed new symptoms of active SLE. At the last documented visit post-ESRD, 42/59 (71%) patients had one or more clinical or serological markers of lupus activity; only 17/59 (29%) patients achieved clinical and serological remission.Thirty-three of 59 (56%) patients had an active HCQ prescription at the time of ESRD. Twenty-six of the 42 (62%) patients with active SLE manifestations post-ESRD and 10/17(59%) patients with no manifestations of active disease post-ESRD were on HCQ. Patients who continued HCQ post-ESRD were more likely to be followed by a rheumatologist (26 [87%] vs 17 [61%], p=0.024), had a higher frequency of documented arthritis (10 [32%] vs 1 [4%], p=0.005), CNS manifestations (6 [20%] vs 1 [4%], p=0.055), and concurrent immunosuppressive medication use (22 [71%] vs 12 [43%], p=0.029).Conclusions: Lupus activity may persist after the development of ESRD. New onset arthritis, lupus-related rash, CNS manifestations, low complement and elevated anti-dsDNA may develop. HCQ may be underutilized post-ESRD. Careful clinical and serological monitoring for signs of active disease and frequent rheumatology follow up is advised in SLE patients both, pre and post-ESRD.

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“…It is recommended that HCQ dose should be reduced in ESRD due to decreased renal excretion in these patients and a concern for potential toxicity [ 40 , 41 ]. In this relatively small sample of SLE ESRD patients, two patients had a documented HCQ related toxicity despite dose adjustment underscoring the need for further studies to examine the relationship of blood HCQ level, drug efficacy, and toxicity in SLE patients with and without ESRD.…”

Section: Discussionmentioning

confidence: 99%

Systemic lupus Erythematosus activity and Hydroxychloroquine use before and after end-stage renal disease

et al. 2020

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Background SLE manifestations after ESRD may be underdiagnosed and undertreated, contributing to increased morbidity and mortality. Whether specific symptoms persist after ESRD or a shift towards new manifestations occurs has not been extensively studied, especially in the non-Caucasian patients in the United States. In addition, hydroxychloroquine (HCQ) prescribing patterns post-ESRD have not been described. The objective of this study was to assess lupus activity and HCQ prescribing before and after ESRD development. Knowledge gained from this study may aid in the identification of SLE manifestations and improve medication management post-ESRD. Methods We performed a retrospective cohort study of SLE patients with incident ESRD between 2010 and 2017. SLE-related symptoms, serologic markers of disease activity, and medication use were collected from medical records before and after ESRD development. Results Fifty-nine patients were included in the study. Twenty-five (43%) patients had at least one clinical (non-renal) SLE manifestation documented within 12 months before ESRD. Of them, 11/25 (44%) continued to experience lupus symptoms post-ESRD; 9 patients without clinical or serological activity pre-ESRD developed new symptoms of active SLE. At the last documented visit post-ESRD, 42/59 (71%) patients had one or more clinical or serological markers of lupus activity; only 17/59 (29%) patients achieved clinical and serological remission. Thirty-three of 59 (56%) patients had an active HCQ prescription at the time of ESRD. Twenty-six of the 42 (62%) patients with active SLE manifestations post-ESRD were on HCQ. Patients who continued HCQ post-ESRD were more likely to be followed by a rheumatologist (26 [87%] vs 17 [61%], p = 0.024), had a higher frequency of documented arthritis (10 [32%] vs 1 [4%], p = 0.005), CNS manifestations (6 [20%] vs 1 [4%], p = 0.055), and concurrent immunosuppressive medication use (22 [71%] vs 12 [43%], p = 0.029). Conclusions Lupus activity may persist after the development of ESRD. New onset arthritis, lupus-related rash, CNS manifestations, low complement and elevated anti-dsDNA may develop. HCQ may be underutilized in patients with evidence of active disease pre- and post ESRD. Careful clinical and serological monitoring for signs of active disease and frequent rheumatology follow up is advised in SLE patients both, pre and post-ESRD.

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2019 Update of the Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA–EDTA) recommendations for the management of lupus nephritis

Cited by 569 publications

References 120 publications

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

Systemic Lupus Erythematosus Activity and Hydroxychloroquine Use Before and After End Stage Renal Disease

Systemic lupus Erythematosus activity and Hydroxychloroquine use before and after end-stage renal disease

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