All patients with lupus need screening for renal involvement with regular checks of serum creatinine and urine dipstick for protein and haematuria. Renal involvement, ranging from a small amount of proteinuria to acute glomerulonephritis and renal failure, affects up to 60% of lupus patients. Usually lupus nephritis will present early in the course of the disease, often within the first five years, but sometimes later so careful monitoring is vital especially as it can recur after treatment is reduced.

Renal biopsy can be of huge value, especially in disease classification, and therefore to decide appropriate treatment as well as providing prognostic information. Patients with proliferative glomerulonephritis (WHO III and IV) unfortunately tend to have a worse outcome, as does biopsy evidence of severe active and chronic histological changes.

The prognosis for patients with lupus nephritis has improved with advances in treatment. This is due to earlier diagnosis, access to treatment pathways involving immunosuppression and appropriate steroid doses. Early diagnosis and treatment is essential for favourable outcomes. Mycophenolate mofetil is being used more widely in specialist units and cyclophosphamide for both membranous and proliferative lupus nephritis. In refractory cases lupus nephritis often responds to anti-CD20 based B-cell depletion and the monoclonal antibody rituximab (or biosimilars) is very effective in these patients. For those that fail immunosuppression and develop end-stage renal failure, renal transplantation has been performed successfully. (For further reading see EULAR nephritis guidelines.)

A greater probability of lupus nephritis has been associated with Afro-Caribbean heritage, low haematocrit, raised serum creatinine, high urinary protein excretion, low C3 complement and poor socioeconomic status. Developments in treatments have meant most patients with lupus nephritis respond well to immune-suppressants and the following advice is also important as these patients are at increased risk of complications such as high blood pressure, heart attacks and infection;
• Monitor and control blood pressure, often using medication such as ACE inhibitors.
• Prevent, and treat infections appropriately, remembering national vaccination programmes such as influenza and pneumococcal prevention.
• Eating a healthy well balanced diet, usually by increasing fruit and vegetables, reducing salt intake, and maintaining a healthy appropriate weight.
• Not smoking or vaping and signposting patients to smoking cessation services as appropriate.
• Taking regular exercise.
• Reduce other cardiovascular disease risks factors, for instance, monitoring cholesterol levels annually.
• If on steroid treatment, osteoporosis prevention may also be needed.

See also the LUPUS UK patient information booklet, “Lupus and the Kidneys”. READ HERE