Differences in management approaches for lupus nephritis within the UK

Abstract

Objectives Outcomes of therapy for lupus nephritis (LN) are often suboptimal. Guidelines offer varied options for treatment of LN and treatment strategies may differ between clinicians or regions. We aimed to assess variations in the usual practice of UK physicians who treat LN. Methods We conducted an online survey of simulated LN cases for UK rheumatologists and nephrologists to identify treatment preferences for class IV and class Ⅴ LN. Results Of 77 respondents, 48 (62.3%) were rheumatologists and 29 (37.7%) were nephrologists. 37 (48.0%) reported having a joint clinic between nephrologists and rheumatologists, 54 (70.0%) reported having a multi-disciplinary team meeting for LN and 26 (33.7%) reported having a specialised lupus nurse. 58 (75%) of respondents reported arranging renal biopsy before starting the treatment. 20 (69%) of the nephrologists, but only 13 (27%) of rheumatologists, reported having a formal departmental protocol for treating patients with LN (p < 0.001). The first-choice treatment of class IV LN in pre-menopausal patients was mycophenolate mofetil (MMF, 41 [53.2%]), followed by cyclophosphamide (CYC, 15 [19.6%]), rituximab (RTX, 12 [12.5%]) or a combination of immunosuppressive drugs (9 [11.7%]) with differences between nephrologists' and rheumatologists' choices (p = 0.026). For class Ⅴ LN, MMF was the preferred initial treatment irrespective of whether proteinuria was in the nephrotic range or not. RTX was the preferred 2nd line therapy for non-responders. Conclusion There was variation in the use of protocols, specialist clinic service provision, biopsies, and primary and secondary treatment choices for LN reported by nephrologists and rheumatologists in the UK.