PATHOGENESIS, EVALUATION AND

DIAGNOSIS OF LUPUSNEPHRITIS,
BIOMARKERS IN LUPUS

BY DR MONIKA
DM RESIDENT NEPHROLOGY
• Much of what is known about pathogenic factors in tissue damage in lupus nephritis was derived
from studies of murine models of lupus, with confirmation as possible in humans.
• These studies utilize multigenic models of lupus (that is, MRL/lpr, NZB/NZW, and NZM congenic
strains) as well as single gene mutants (that is, DNAse 1, Nrf2, or Fcγ receptor (FCγR) knockouts)
• These models share common features of human disease such as anti-dsDNA Ab and proliferative
nephritis, but differ in their renal cytokine/chemokine profile, cellular infiltration and
acuity/chronicity of disease
• Thus, as in human disease, there is heterogeneity of pathogenic mechanisms in murine lupus
nephritis.
Summary of proposed pathogenic mechanisms in
tissue injury in lupus nephritis. Top right: The first step
leading to nephritis involves the production of
autoantibodies to self-antigens followed by formation of
immune complexes (ICs) in glomeruli. IC deposition
leads to complement activation and intrinsic renal cell
activation (mesangial cells (MC) and endothelial cells
(EC)), both leading to local chemokine and cytokine
inflammation. Chemokine expression leads to an influx of
inflammatory cells such as lymphocytes and
macrophages. Left: Influx of immune cells leads to
interstitial as well as further glomeruli inflammation and
EC activation. Activated renal cells (MC and podocytes)
and infiltrating immune cells (macrophages and dendritic
cells (DCs)) produce reactive nitrogen (nitric oxide (NO))
and reactive oxygen species (ROS). The combined
expression of cytokines and ROS results in further renal
inflammation and fibrosis, resulting in cumulative tissue
destruction both at the glomerular level (top right) and the
tubular level (left). Bottom right: Lymphocyte interactions
and functions such as cytokine expression and antibody
production contribute to inflammation and damage in the
tubules and glomeruli. BCR, B-cell receptor; FcR, Fc
receptor; MCP-1, monocyte chemoattractant protein-1;
STAT, signal transducers and activators of transcription;
TCR, T-cell receptor.
PATHOGENESIS

• abnormalities of immune regulation lead to a loss of self-tolerance and subsequent autoimmune

responses
• decreased number of cytotoxic and suppressor T cells; increased helper (CD4+) T cells
• polyclonal activation of B cells; defective B-cell tolerance
• dysfunctional T-cell signaling; and abnormal Th1, Th2, and Th17 cytokine production.
• failure of apoptotic mechanisms to delete autoreactive B- and T-cell clones may promote their
expansion and autoantibody production
• antigen mimicry - Exposure to viral or bacterial peptides containing sequences similar to native
antigens may lead to stimulation of autoantibody production
• Defective clearance of apoptotic cells and prolonged exposure to nuclear antigens may trigger
immune responses through interactions with toll-like receptors.
• Regardless of the specific mechanism(s), autoantibody production is directed against such nuclear
antigens as ds-DNA, Sm, RNA, Ro, La, and histones
• formation of circulating immune complexes (CICs) and their deposition in tissues followed by
complement activation is important for certain patterns of glomerular damage
• Immune complexes are also detectable in the skin at the dermal–epidermal junction and in the
choroid plexus, pericardium, and pleural spaces.
• Renal involvement in SLE has been considered a human prototype of classic experimental chronic
immune complex–induced GN
• The chronic deposition of CICs plays a major role in the mesangial and the endocapillary
proliferative patterns of LN.
• Immune complex size, charge, avidity, local hemodynamic factors, and the clearing ability of the
mesangium all influence the localization of CICs within the glomerulus
• In diffuse proliferative LN, the deposited complexes consist of nuclear antigens (e.g., DNA) and
high-affinity complement–fixing immunoglobulin G (IgG) antibodies.
• In other SLE patients, rather than deposition of CICs, the initiating event may be the local binding of
cationic nuclear antigens such as histones to the subepithelial region of the glomerular capillary wall
followed by in situ immune complex formation.
• After immune deposits form in the glomerulus, the complement cascade is activated, leading to
complement-mediated damage, activation of procoagulant factors, leukocyte infiltration, release of
proteolytic enzymes, and production of various cytokines regulating glomerular cellular proliferation
and matrix synthesis.
• Glomerular damage may be potentiated by hypertension and coagulation abnormalities
• Recent studies have documented focal segmental necrotizing glomerular lesions without significant
immune complex deposition, resembling a “pauci-immune” pattern, with or without ANCAs
• This may be an independent mechanism of glomerular and vascular damage in some patients with LN.
• The presence of APL antibodies directed against a phospholipid-β2 glycoprotein complex and their
attendant alterations in endothelial and platelet function, including reduced production of prostacyclin
and other endothelial anticoagulant factors, activation of plasminogen, inhibition of protein C or S, and
enhanced platelet aggregation, can also potentiate glomerular and vascular lesions
PATHOLOGY OF LUPUS NEPHRITIS
GENETICS OF LN
• GWA studies have identified risk genes in LN that are not otherwise seen in patients with SLE
without nephritis, including apolipoprotein L1 (APOL1), platelet-derived growth factor
receptor alpha (PDGFRA), and hyaluronan synthase 2 (HAS2).
• Genetic modifications in HLA alleles are also associated with LN. HLA-DR4 and HLA-DR11
appear to protect against LN, while HLA-DR3 and HLA-DR15 confer increased risk.
• Allelic variants in the APOL1 gene are associated with increased risk for kidney failure in
black populations and in LN; those with 2 risk alleles for APOL1 have more than 2.5-fold
increased risk for developing kidney failure compared with those without risk alleles
P A TH OP H Y SI OL O GY OF L N
• Abnormalities in innate and adaptive immunity
• autoantibodies directed against nuclear and cellular antigens

immune complex formation

accumulation of immune complexes in glomeruli.

Immune complexes may deposit in glomeruli from circulation may form in situ if autoantibodies

target intrinsic glomerular antigens (such as annexin 2)

antigens that are released during apoptosis and/or arise when apoptotic debris (including chromatin) is incompletely cleared.

Chromatin can also activate intrarenal dendritic cells increase the interaction of T and B cells, and enhance the production of anti chromatin
antibodies.

• Intraglomerular immune complexes can activate complement and engage leukocyte Fc receptors to initiate intrarenal inflammation and injury.
• Complement mediated kidney damage, especially through the alternative pathway, has been observed in murine and human LN
Interstitial plasma cells generated from T- and B-cell aggregates within the kidney
tubulointerstitium

produce clonally restricted autoantibodies

This kidney specific autoimmunity is facilitated by intrarenal IFN-α expression

Immune complexes are ligands for Toll-like receptors (TLRs), specifically TLR7
and TLR9

TLR7/9 engagement induces IFN-α expression by plasmacytoid dendritic cells

enhances production of antigen-presenting cells, encourages autoreactive B-cell

differentiation to plasma cells, and enhances production of CD4 helper T (TH) and CD8
memory T cells

further autoantibody generation and immune complex formation

Abnormalities in B-cell tolerance leading to autoantibody production

• Human regulatory T cells reduced in number and functionally defective in SLE

Autoreactive B cells process and present self-antigens to T cells, promoting

proinflammatory cytokine activation
• TH1 cytokines overexpressed in LN kidneys and promote inflammation through macrophage,
complement, and Fc receptor activation

TH1 cells promote differentiation and proliferation of B cells and assist class switching of autoantibodies to isotypes
that are more specific for renal antigens.

IgG1 and IgG3 autoantibodies have been associated with LN

and promote intrarenal inflammation through complement-
mediated leukocyte recruitment
• Immune complex clearance by leukocytes is impaired by the presence of low-affinity Fcγ
receptors and autoantibodies to C1q and C3b.
• Engagement of low-affinity Fcγ receptors by immune complexes promotes leukocyte
activation.
• Activated neutrophils and macrophages directly injure the kidney through secretion of oxygen
free radicals and proteolytic enzymes.
• Dying neutrophils release neutrophil extracellular traps.
• These chromatin structures bind autoantigens and further stimulate IFN-α secretion from
dendritic cells, amplifying intrarenal autoimmunity
S P O N T A NE O U S M O U S E M OD E LS O F S LE A N D L N

1. The MRLlpr and gld models –

The MRL strain was developed in 1976 by Murphy and Roths in an effort to transfer a mutation for anchrondroplasia
from the leukemic strain AKR
The MRL genome is primarily derived from the LG/J strain with contributions from AKR, C3H and C57BL/6
In the 12th generation of inbreeding a MRL substrain was identified that developed lymphadenopathy characterized
by massive accumulation of lymphocytes including an unusual population of CD4negCD8neg B220+ T cells.
Backcross experiments revealed the defect to be the result of a recessive mutation termed lymphoproliferation (lpr).
In the early 1990s Shigekazu Nagata’s group identified lpr as insertion of an early transposable element in intron 2 of
the Fas gene resulting in a loss of protein expression as a result of truncated translation
MRLlpr mice are unusual in that they show a full spectrum of SLE features including arthritis, inflammatory skin
lesions and glomerulonephritis.
Both male and female mice are affected by the lpr mutation, although disease is more severe in females
In comparison to other SLE models MRLlpr mice show accelerated mortality with 50% death at approximately 24
weeks due to renal failure
unlike other lupus models (e.g. NZB/NZW F1 discussed below), nephritis in MRLlpr mice is independent of FcγRs so
the models relevance to human lupus may not be totally appropriate
The gld mutation
1st reported by Roths, Murphy and Eicher in C3H/HeJ mice with lymphoproliferation similar to that
observed in MRLlpr mice
The gld mutation was later identified as a point mutation in the cognate receptor for Fas, Fas ligand
(FasL), that abrogated functional Fas/FasL interactions
Lymphocyte expansion and humoral autoimmunity is similar in gld compared to the MRLlpr strain,
however gld mice have a much longer lifespan.
• Gld mouse glomeruli show significant renal IgG deposition by 22 weeks, although a majority of
mice do not show signs of glomerular pathology
• gld mice exhibit reduced renal pathology with anti-glomerular antibody-driven injury suggesting a
dichotomy in the contribution of Fas and FasL in LN
• Thus the use of gld mice can provide valuable insight of the relative contribution of Fas and FasL to
mechanisms of autoimmune pathology in the kidney.
The BXSB model—
developed in the 1970s by crossing of C57BL/6 and SB/Le mice (hence the BXSB nomenclature)
This strain is unique in that male mice show significantly enhanced disease compared to females due to the presence of the
y-linked autoimmune accelerator (Yaa) driving autoimmunity
Elegant chromosomal hybridization studies showed the Yaa mutation is a translocation of a telomeric region of the X
chromosome to the Y chromosome resulting in duplication of several genes including toll like receptor 7 (TLR7)
increasing both expression and function
As TLR7 binds RNA, this may explain the unique serum autoantibody profile BXSB mice exhibit.
Serum reactivity to DNA and histones is comparatively low, however BXSB mice develop reactivity to nucleolar antigens
including ribonucleoproteins (RNP) giving rise to a “speckled” pattern when anti-nuclear antibody (ANA) assays are
performed
Male mice show significant lymphoproliferation, but in contrast to MRLlpr mice the cellular composition is primarily B
cells.
Male BXSB mice show prominent deposition of IgG and C3 in the mesangium and capillary wall and develop fulminant
nephritis with 50% mortality at 5 months of age and 90% mortality at 8 months
Death is due to renal failure as male BXSB mice develop exudative, proliferative nephritis with a significant neutrophil
infiltration and prominent proteinuria by 3 months
Female mice show a weaker disease phenotype with 50% mortality around 15 months; however both male and female
mice die due to glomerulonephritis and renal failure.
• The NZB/NZW F1 model—
• The NZB/NZW F1 hybrid (B/W) model of SLE and LN is the oldest of the “classical” models of spontaneous disease
• B/W mice are regarded by many to be the closest approximation of human SLE due to the characteristics of disease
development and the underlying genetics driving autoimmunity.
• B/W mice are derived by crossing two strains with mild autoimmune characteristics (New Zealand black [NZB] and New
Zealand White [NZW]).
• The resultant F1 generation animals show significant autoimmunity with high levels of anti-DNA and anti-chromatin antibodies
• Female mice are more severely affected and serum IgG reactivity to DNA is detectible by 3 months
• Unlike BXSB or MRLlpr mice there is little lymphoid hyperplasia, although mice show develop splenomegaly and signs of
chronic polyclonal B cell activation.
• Female B/W mice have 50% mortality around 8 months and >90% mortality after 1 year of age
• Death is due to LN and B/W mice develop progressive proteinuria beginning around 5 months and azotemia from
approximately 7 months onward
• The nephritis is sclerotic with heavy proteinaceous deposits in the mesangium, tubular cast formation, diffuse proliferation of
glomerular cells, prominent crescent formation, and a significant periglomerular and interstitial monocytic infiltrate.
• Female B/W mice exhibit heavy mesangial and occasional capillary IgG and C3 deposition at 5 months and as B/W mice age
there is increased extra-glomerular, peri-tubular, and arteriolar deposition
An accidental backcross between B/W and NZW mice lead to the establishment of the inbred
New Zealand Mixed (NZM) mouse strains, several of which show highly penetrant SLE and
LN resembling disease in parental B/W mice
NZM2410 stain
used extensively to elucidate the genetics underlying SLE and its pathologic features.
driven primarily by 3 susceptibility loci (Sle1, Sle2, and Sle3 on chromosome 1, 4, and 7
respectively) that act in a threshold manner to drive disease.

As congenics for each susceptibility loci are available these strains may provide useful tools to
study genetic interactions and the development of LN.
 GENETIC MANIPULATION: GENE DISRUPTION MODELS OF LN
majority of knock out models are generated by gene disruption in either the C57BL/6 or BALB/c mouse strains
Fcgr2b knock out (Fcgr2b−/−) mouse.

Fcgr2b encodes for a single chain FcγR unique among the classic FcγRs in that the cytoplasmic domain contains an inhibitory ITIM
motif negatively regulating signal transduction in B cells, macrophages, and dendritic cells.
Originally derived from 129/SvJ cells,
a mixed genetic background and showed no signs autoimmunity.
However, when backcrossed 12 generations to the C57BL/6 (BL/6) and BALB/c strains a striking dichotomy was observed.
BALB/c Fcgr2b−/− mice showed no overt autoimmunity, but female BL/6 Fcgr2b−/− mice developed SLE with high-titer anti-DNA
and anti-chromatin IgG by 5 to 6 months paralleling polyclonal B cell activation and splenomegaly
Likewise, female BL/6 Fcgr2b−/− mice exhibited severe LN (manifesting between 5 and 7 months) with proliferative lesions, crescent
formation, peri-glomerular and interstitial infiltration of macrophages and B cells, and significant glomerular IgG and C3 deposition
The immune deposits are primarily IgG and all subclasses are represented, although IgG2b and IgG2c predominate.
IgG deposition is mainly mesangial but subendothelial deposits are frequent
Mortality is 50% at 9 months and 80% at 1 year due to LN in female mice while males show mild autoimmunity but a normal lifespan
Genetic studies have suggested the presence of susceptibility loci on the BL/6 background that drive autoimmunity and proteinuria in
Fcgr2b−/− mice
However, several reports have called into question the relative role of FcγRIIb in the disease phenotype, and it is likely the combination
of Fcgr2b gene disruption and flanking 129/SvJ genomic material inherited via linkage disequilibrium drives SLE and LN in this
model
 INDUCIBLE MODELS OF NEPHRITIS: PRISTANE AND
OTHER APPROACHES
Intraperitoneal injection of pristane (2,6,10,14 tetramethylpentadecane) is a standard approach to create ascitic fluid for
monoclonal antibody production.
However, Satoh and Reeves reported within 2 months of pristane administration, otherwise healthy BALB/c mice developed
anti-RNP (and later anti-DNA and anti-histone) antibodies
Interestingly, anti-RNP antibodies class switched to IgG while anti-DNA antibodies were almost entirely IgM, in stark contrast to
most mouse SLE models
Pristane injected BALB/c mice developed some features of nephritis 6 months after injection with focal to diffuse proliferative
glomerulonephritis and moderate proteinuria
Moreover, pristane injected mice exhibited a renal monocytic infiltrate and mesangial and sub-endothelial deposition of IgM and
IgG with mesangial C3 deposits.
Survival studies with this model are confounded by other pathologies induced by pristane injection including plasmacytoma
Nevertheless, it is unlikely the mice die due to nephritis, and there is little mortality up to 6 months post-pristane injection.
Most mouse strains are susceptible to pristane-induced autoimmunity although the development of LN is variable
Sex is also a factor in pristane susceptibility with female mice showing heightened susceptibility to pristane-driven SLE in the
SJL/J strain
It is worth noting that pristane-treated BALB/c mice develop other autoimmune phenotypes such as capillary hemorrhagic
pathology in the lung and TNFα-driven arthritis that may resemble arthralgia and capillaritis occurring in SLE patients
Thus this model may useful in examining environmental triggers of LN in the context of more broad-spectrum pathology
nephrotoxic serum nephritis model of crescentic glomerulonephritis

serum sickness model of IC nephritis

DI A G NOSI S A ND C LI NI C A L P R ESENTA TI ON
 presence of ≥4 ACR criteria
96% sensitivity and specificity
for lupus
 In SLICC classification system
SLE can be diagnosed with
biopsy-proven immune
complex nephritis in the
presence of ANA or anti-
dsDNA, without other
extrarenal disease
manifestations.
D/Ds –
 Fibromyalgia, Sjögren Syndrome, Thrombotic Microangiopathies, Primary Antiphospholipid
Syndrome, Dermatomyositis, Systemic Sclerosis, And Mixed Connective Tissue Disease

 IgA Vasculitis (HSP), AAGN , Bacterial Endocarditis, And Cryoglobulinemia

• A positive test result for blood and/or protein on urine dipstick in a patient with lupus is
suggestive of nephritis
• The urine dipstick may be falsely negative for proteinuria when the urine concentration is
dilute (ie, low specific gravity) or falsely positive for significant proteinuria when urine is
highly concentrated (ie, high specific gravity).
• Additionally, the urine dipstick is highly sensitive for blood and may be falsely positive or
represent bleeding from a nonglomerular source, such as menstruation in a young woman.
• Therefore, urine microscopy should always accompany the dipstick.
• Findings specific for glomerular bleeding associated with nephritis include dysmorphic RBCs,
specifically acanthocytes and RBC casts
• Microscopic hematuria is present in ~80% of patients with LN, while RBC casts are present in
30%.
• White blood cells and white blood cell casts in the absence of infection may also be present and
are consistent with intrarenal inflammation that can be present in LN
• By definition, proteinuria must be present to clinically diagnose LN.
• Nephrotic-range proteinuria (protein excretion > 3.5 g/d) is found in up to 50% of cases.
• Quantification of proteinuria
• UPCR in a random spot specimen or a 24-hour urine collection.
• UPCR from a spot sample - can be inaccurate in LN, over- or underestimating the true level
of proteinuria.
• Thus, although a spot urine specimen can be used to screen and follow trends in individual
patients, for critical clinical decisions such as changing treatment, it should be verified by a 24-
hour urine collection.
• UPCR in 24-hour urine - attenuates collection errors.
• Even an intended 24-hour collection that is at least 50% complete correlates well with a
complete 24-hour collection.
• A first-morning-void UPCR also accurately reflects 24-hour proteinuria in LN.
THE ROLE OF THE KIDNEY BIOPSY

• Percutaneous kidney biopsy - gold standard for diagnosis and classification of LN

• when urine protein excretion exceeds 500 mg/d.
• any level of proteinuria with decreased GFR that is not readily attributed to another cause, for
example, a new medication.
• Alternatively, a biopsy may not be required if the only clinical abnormalities indicative of LN
are asymptomatic microscopic hematuria or proteinuria with protein excretion < 500 mg/d in
the absence of active urine sediment
• repeat kidney biopsies have been done on a “for cause” basis, for example, a flare of LN,
treatment-resistant disease, or in cases in which it is unclear whether persistent proteinuria is
due to active disease or chronic nephrosclerosis
• Recognized by Gross,' and Ginzler and Fox2 were correctly
believed by these authors to be derived from altered nuclei.
• So unique to systemic lupus are the changes leading to the
formation of these bodies and aggregates that they have been
regarded as pathognomonic of this disease, and serve as additional
criteria for its anatomic diagnosis.
• With the discovery of the LE cell phenomenon- it became obvious
that the hematoxylin bodies were the counterparts in the tissues of
the LE bodies formed in vitro.
• Histochemical characterization contained partially depolymerized
DNA, led to the concept that a depolymerase (DNASE) was
activated in systemic Lupus.
• However, serum levels of DNASE were not found to be
significantly elevated in this disease and it was hypothesized that
depolymerization of DNA in the LE cell was due to release of an
intracellular DNASE from an intracellular inhibitor of DNASE by
an action initiated by the circulating LE factor of the blood.
• It has since been proposed that the LE factor itself permits entrance
of serum protease into the cytoplasm which in turn releases the
intracellular deoxynbonuclease from its inhibitor.
 SD I
• The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (SDI) was
developed in 1996 to assess an ongoing reflection of disease activity in SLE patients and to measure irreversible damage resulting from SLE
disease activity and its treatment.
• All damage is scored from the time of SLE diagnosis onward regardless of whether or not the damage is attributed to lupus
• SDI contains items that represent permanent, irreversible damage in a lupus patient.
• Items should be present for at least 6 months with the exception that manifestations such as MI and stroke are recorded once they occur.
• Damage is defined for 12 organ systems:
1. ocular (range 0–2),
2. neuropsychiatric (0–6)
3. renal (0–3)
4. pulmonary (0–5)
5. Cardiovascular (0–6)
6. peripheral vascular (0–5)
7. gastrointestinal (0–6)
8. musculoskeletal (0–7)
9. skin (0–3)
10. endocrine (diabetes) (0–1)
11. gonadal (0–1)
12. malignancies (0–2).

Damage over time can only be stable or increase, theoretically to a maximum of 47 points
BIOMARKERS
• A biologic, genetic or a chemical characteristic that is measurable and its levels correlate with a
biologic event (physiological or pathological).

An ideal biomarker for LN

would be the one which
reflects renal disease
activity better, correlates
with renal histology,
predicts flares, is easily
measurable, not affected by
age, gender and ethnicity,
is specific to SLE and renal
involvement for making an
early diagnosis of LN
U R I N A RY B I O M A R K E R S I N L N

NGAL

KIM 1- a transmembrane glycoprotein, usually

e x p r e s s e d i n l o w l e v e l s i n k i d n e y, h i g h l y u p r e g u l a t e d
in AKI, similar to NGAL.
Nozaki & colleagues – uKIM-1 elevated in active LN,
correlated with proteinuria & tubular infiltration &
injury

MCP-1 – a metaanalysis of 399 pt from 8 centers

demonstrated uMCP-1 significantly higher in active
LN, than inactive LN & control

T U M O R N E C R O S I S FA C T O R - L I K E I N D U C E R O F
APOPTOSIS (TWEAK) –
m u l t i f u n c t i o n a l c y t o k i n e , i n v o l v e d i n i n f l a m m a t o r y,
fibrotic & apoptotic pathway
uTWEAK levels correlated better with LN disease
activity than anti-dsDNA & complement level

Combining uTWEAK & uMCP levels to predict LN-

improved Sn & Sp over individual marker & ROC AUC
to 0.887

U R I N A RY B I O M A R K E R PA N E L – 6 U R I N A R Y
BIOMARKERS
NGAL, MCP-1, CERULOPLASMIN, ADIPONECTIN,
HEMOPEXIN & KIM-1
M AY H E L P G U I D E T / T D E C I S I O N I N L N
• CONVENTIONAL BIOMARKERS IN LN –

– Renal histology - invasive procedure

– Urinary biomarkers - proteinuria, UPC ratio and urine active sediment

– serum biomarkers - creatinine clearance, serum anti-dsDNA antibodies, C3 and C4.

• GENETIC BIOMARKERS IN LN - MHC antigen, interferon responsive factor-5 (IRF5), integrin-a M (ITGAM),

STAT4 and FCcRIIA (FCGR2A) evidence is weak for genes like CRP, Programmed cell death-1 (PD1),

angiotensinogen (ATG) and Mannose Binding Lectin (MBL)

• CYTOKINES AND ADHESION MOLECULES –
1) Monocyte chemoattractant protein-1 (MCP-1) also known as chemokine ligand-2 (CCL2)
• Urinary MCP-1 shows good correlation with disease activity.
• Longitudinal studies also highlight that its levels rise 2–4 months prior to flare and remain high during the flare
• higher in patients with proliferative disease (LN classes III and IV) compared to class V
2) Tumor necrosis factor-like inducer of apoptosis (TWEAK) is a member of the TNF superfamily,
• mainly secreted by activated monocytes and macrophages
• mediates its effects through fibroblast growth factor inducible protein 14 (Fn14) receptor.
• This receptor is present on a variety of renal cells
• like podocytes, tubular cells and mesangial cells.
• Its interaction with the receptor induces several proinflammatory cytokines such as MCP-1, IFN-c inducible
protein 10 (IP-10) which give a proliferative and survival signal to leucocytes and maintain the inflammatory
milieu
• rise 4–5 months before the renal flare and remain elevated for the same period after the flare.
3) Neutrophil gelatinase-associated lipocalin (NGAL) –
• expressed by many types of cells, including neutrophils and renal tubular epithelial cells.
• A marker of AKI due to several conditions, such as chemotherapy-induced nephrotoxicity and
renal failure following transplantation, a marker of renal injury following cardiac surgery
• levels of uNGAL higher in patients with active LN as compared to inactive disease, healthy
controls and other inflammatory arthropathies, such as juvenile idiopathic arthritis (JIA).
• Its levels decrease with treatment and correlate with disease activity
• levels rise 3–6 months before renal flare and it performs better than anti-dsDNA antibodies in
predicting renal flare
• 4) IFN inducible chemokines play an important role in T-cell trafficking into the organs.
• IP-10 (Interferon-c inducible protein-10) - also known as CXCL 10
• Secreted by monocytes and endothelial cells in response to stimulation by IFN
• acts via its receptor CXCR3 on T-cells
• responsible for their trafficking into the inflamed organ.
• serum and urinary levels of IP-10 higher in active nephritis as compared to inactive disease but
only urinary IP-10 distinguished between LN and active nonrenal SLE.
• levels decreases with treatment but it not better than the conventional disease activity
parameters
• 5) CXCR3 + CD4 + T-cells in the urine –
• Enghard et al. identified these cells as biomarkers of proliferative LN.
• They defined a cut-off of 800 CD4 + T cells in 100 mL of urine which was specific for active nephritis
• 6) soluble IL-2 receptor (soluble CD25) - a T-cell activation marker in urine and serum
• 7) Tsai et al. studied that levels of both IL-6 and IL-8, were higher in the urine of patients with active LN,
most of which were having class IV LN, as compared to inactive nephritis and controls.
• The levels decreased with cyclophosphamide in all patients except those who continued to have high disease
activity and developed CNS lupus.
• 8) Vascular cell adhesion molecule-1 (VCAM-1) – plays an important role in holding the leucocytes in the
inflamed kidneys.
• tested in urine as well as serum and found to have good correlation with LN disease activity.
• higher in proliferative LN as compared to other classes
• Singh et al. have found a good correlation of urinary VCAM-1 with LN disease activity index
• study by Abd-Alkareem noted that urinary levels of VCAM-1 are higher when renal biopsy shows features of
advanced histopathological changes, that is, LN class III, IV or V
• COMPLEMENTS AND AUTOANTIBODIES
1. C3 and C4 are traditional markers of disease activity.
• low levels signify consumption in the clearing process and correlate with disease activity.
• Apart from C3 and C4, their degradation products also have been tested as biomarkers in LN.
• Serum C3d could not differentiate between active renal disease and active non-renal disease,
whereas urinary C3d could.
• erythrocyte bound C4d has been shown to be a marker of systemic disease activity of SLE and
renal disease activity of LN.
• So it cannot be said with certainty that C4d is a marker of renal-specific disease activity
• 2) anti-C1q antibodies - Multiple studies have shown almost 100% NPV for renal
involvement in SLE.
• not better than anti-dsDNA antibodies.
• Moroni et al. found that if anti-C1q antibodies are normal along with anti-dsDNA antibodies
and serum C3 and C4 levels, LN was unlikely.
• Anti-C1q only marker that predicted flare in both class V & Proliferative LN, Sn 80.5%, Sp
71% in Proliferative LN
• Anti-C1q & C3/C4 better at identifying current flare rather than predicting future flares
• Anti-dsDNA & C3/C4 - Sn 70-79% in Proliferative LN
Novel Auto Ab –
• Cell specific & GBM targets
• Bruschi & colleagues identified IgG2 Ab to annexin A1 in
nephritic glomeruli & same isoform in sera of LN pts,
which decreased after 12 mnth of t/t, suggesting a role in
both as diagnostic & disease activity marker
• Auto-Ab targeting alpha-enolase – in several immune
mediated GN, mixed cryoglobulinemia & 1ry MN.
• role in both as diagnostic & disease activity marker
• Alpha enolase – multifunctional protein
• Intracellularly serve as a glycolytic enzyme, act as
plasminogen receptor on cell surface, may be released from
neutrophil extracellular traps (NETs) during NETosis which
trigger auto-Ab formation

• Some SLE auto-Ab protect against nephritis –

• Anti-pentraxin 3- decrease complement activation
GENE EXPRESSION BIOMARKERS
• Proteomics-
• separation and analysis of proteins in any biological fluid
• several techniques available.
– two-dimensional gel electrophoresis
– liquid chromatography – tandem mass spectrometry with a higher sensitivity as compared to 2-D gel
electrophoresis
– newer techniques, such as surface enhanced laser desorption/ionization time of flight mass
spectrometry (SELDI-TOF-MS) and matrix-assisted laser desorption/ionization time of flight mass
spectrometry (MALDI-TOF-MS).
• Newer techniques more sensitive, capable of using very little amount of urine (5–10 lL), able to
test multiple urine samples simultaneously and can detect low molecular-weight proteins (< 20
kDa)
• Prostaglandin D synthetase (PGDS)
• Serum amyloid-p (SAP)
• Total proteases
• Superoxide dismutase (SOD)
• 20 And 25 Amino Acid Isoforms Of Hepcidin Fragments Of Albumin And A-1 Antitrypsin -
differentially expressed during flare cycles.
• Hepcidin 20 increased 4 months prior to renal flare and hepcidin 25 decreased at renal flare and returned
to baseline 4 months after the flare, making them markers of flare and response to therapy, respectively
• Transferrin (Tf), Ceruloplasmin (Cp), Alpha1-acid-glycoprotein (AGP) And Lipocalintype
Prostaglandin-d Synthetase (L-PGDS) - levels in the urine of patients with active LN significantly
higher as compared to inactive LN & SLE without nephritis
• except Cp, all three were able to predict flare of LN when measured in the urine 3 months prior to flare.
THANKS
• Treatment response in LN is defined clinically and generally stratified into complete (CR),
partial (PR), and no response.
• CR
• a reduction in protein excretion to <0.5 g/d based on a 24-hour urine collection with normal
serum creatinine or serum creatinine level within 15% of previous baseline is considered a CR.
• PR
• > 50% reduction in proteinuria and to nonnephrotic levels, with serum creatinine level within
25% of previous baseline.
• Nonresponders
• patients who show some response but do not meet PR criteria, have no improvement in
parameters, or are worse.
• responses are typically evaluated at 6 to 12 months.
• a retrospective analysis of 1-year clinical response metrics from the Euro Lupus Nephritis Trial
(ELNT) were correlated with kidney outcomes after at least 7 years of follow-up.
• Proteinuria with protein excretion < 800 mg/d at 1 year was the best predictor of good long-term
renal outcome.
• The addition of serum creatinine level and microscopic hematuria did not improve the prediction
model.
• These findings were confirmed in independent cohorts.
• Although these data suggest that the current definition of LN response may need to be modified
to create a uniform definition according to proteinuria level at 1 year, the patients studied were
predominantly white.
• Confirmation from prospective clinical trials in multiethnic populations is required before a
relaxed proteinuria definition for clinical response can be formally accepted into clinical practice
• Hydroxychloroquine
• most commonly prescribed antimalarial in SLE.
• can cause pigment changes in the macula of the retina that can cause vision loss if
unrecognized.
• Risk factors for HCQ associated vision loss
– daily dose > 400 mg/d or
– cumulative dose > 1,000 g
– underlying retinal or macular disease
– age older than 60 years
– underlying kidney or liver disease (drug is eliminated by both routes).
• Dose - 5 mg/kg/day (maximum, 400 mg/d)
• baseline eye examination and evaluations every 12 months
MANAGEMENT OF PROLIFERATIVE LN: INDUCTION THERAPY
ELNT
• compared the standard-dose (NIH) regimen cyclophosphamide (0.5-1 g/m2 monthly pulses for
6 months, total dose exposure of 9-12 g) with a low-dose IV cyclophosphamide regimen of 500
mg every 2 weeks for 6 doses (total dose exposure of 3 g).
• Outcomes were measured at 1 year with 10-year follow-up.
• The 2 regimens were equally effective for short-term remission induction (54% remission for
low-dose vs 46% in high-dose cyclophosphamide at 1 year) and long-term renal preservation.
• There were fewer adverse events in patients treated with low-dose cyclophosphamide.
• This study was performed in a predominantly white population, but more recent RCTs using
this low-dose strategy also suggest efficacy in multiethnic LN populations
A SP R EV A LU P US M A NA GEM EN T ST UD Y ( A L M S)

• multiethnic prospective study of 370 patients that compared MMF (3 g/d) with NIH-regimen
cyclophosphamide for LN induction
• demonstrated equal efficacy at 6 months and after 3.5 years.
• Total (CR plus PR) response was 56% in the MMF group (8.6% CR) and 53% in the
cyclophosphamide group (8.1% CR) at 6 months.
• CR rates increased and remained similar between groups (62% for the MMF group and 59%
for the cyclophosphamide group) after 3.5 years of treatment.
• Adverse event rates were similar between groups, but gastrointestinal toxicity and the overall
dropout rate was higher in the MMF-treated group.
• However, MMF does not increase the risk for infertility or malignancy like cyclophosphamide
and has now largely replaced cyclophosphamide as the first-line therapy for the induction
phase.
• Taking all these trials together, either low-dose cyclophosphamide or MMF may be considered
acceptable options as first-line induction therapy for proliferative LN.
• A direct comparison of low-dose cyclophosphamide to MMF in a South Asian LN cohort found
similar 6-month renal response rates.
• Thus, our approach to LN induction therapy is to treat with either MMF or low-dose
cyclophosphamide and reserve NIH-regimen cyclophosphamide or oral cyclophosphamide for
severe or resistant cases
MANAGEMENT OF PROLIFERATIVE LN: MAINTENANCE THERAPY

• purpose of maintenance therapy is 2-fold:

– (1) consolidate responses into durable complete remissions without the toxicity of induction regimens
– (2) continue suppression of autoimmunity to prevent LN flare.
• MMF or azathioprine commonly used
• directly compared in 2 RCTs.
• In a predominantly white population (the MAINTAIN nephritis trial, n = 105), there was no difference in time to
first renal flare between MMF and azathioprine.
• However, in a multiethnic study (ALMS maintenance trial, n = 227), MMF (2 g/d) was found to be superior to
azathioprine (2 mg/kg per day) in preventing treatment failure (16.4% vs 32.4%, respectively; P = 0.003) defined as
a composite end point of death, kidney failure requiring KRT, doubling of serum creatinine level, LN flare, or need
for rescue therapy.
• MMF has become the therapy of choice for LN maintenance in most cases.
• However, azathioprine remains an acceptable alternative and is preferred in specific situations, such as pregnancy,
for which azathioprine can be safely used but MMF is contraindicated.
• Before initiating azathioprine treatment, we recommend checking thiopurine methyltransferase (TPMT) activity.
• Genetic mutations causing TPMT deficiency are reported to be as high as 6 per 1,000 persons.
• Azathioprine use should be avoided in the setting of TPMT deficiency because it can lead to potentially life-
threatening bone marrow toxicity at usual doses
• The optimal duration of maintenance therapy is unclear and not evidence based.
• 12 to 36 months ,should be continued for at least 12 to 18 months after CR has been achieved.
• There is even less guidance in the setting of persistent PR, and in these cases, a repeat kidney
biopsy may be needed to avoid over- or underimmunosuppression, as described previously
• Finally, treatment may need to be continued indefinitely in some patients and should be
considered based on disease severity and relapse risk for that individual
CORTICOSTEROIDS

• in a prospective pilot study of 50 patients with class III, IV, or V LN, oral corticosteroids were not used
during induction.
• Instead patients received rituximab and MMF plus 2 boluses of IV methylprednisolone (500 mg each).
• After 12 months, 52% of patients achieved CR, comparable to previously reported LN response rates
using standard high-dose corticosteroid therapy.
• This suggests that the traditional approach to LN management may overexpose patients to
corticosteroids, increasing toxicity risk without adding benefit.
• Though concrete recommendations cannot be made until further support is provided from large
prospective clinical trials, we suggest that close attention be paid to the dose and duration of
corticosteroid therapy in the management of LN.
• Complete corticosteroid withdrawal should be attempted in all patients who achieve a clinical
response.
EMERGING THERAPIES IN LN
1) B-Cell Depletion in LN-
• LUNAR Study - phase 3 Lupus Nephritis Assessment With Rituximab failed to show that rituximab
added to SOC was superior to SOC alone
• A phase 2 study is evaluating whether more potent B-cell depletion may be required for LN.
In this 2-year study, a combination of SOC and Obinituzumab, a type II anti-CD20 monoclonal
antibody that has shown superiority to rituximab (a type I drug) in depleting tissue B cells in
lymphoma, is being compared to SOC alone (Clinical- Trials.gov identifier NCT02550652).
• Belimumab - a humanized monoclonal antibody against BAFF and FDA approved for nonrenal
SLE, is being evaluated in 2 prospective RCTs to determine its ability to improve LN response and
limit flare beyond SOC (ClinicalTrials.gov identifiers NCT01639339 and NCT02260934)
• B-cell depletion with rituximab may be considered in cases of
– disease resistance
– as a maintenance therapy to help prevent disease relapse in patients intolerant or refractory to MMF or
azathioprine
MULTITARGET APPROACH IN LN

• CNI with MMF and corticosteroids

• A prospective study of 302 Chinese patients compared 6 months of MTT with tacrolimus (4
mg/d) and MMF (1 g/d) with NIH-regimen cyclophosphamide.
• MTT group demonstrated superior 6-month CR rates compared with NIH-regimen
cyclophosphamide (46% vs 26%, respectively; P < 0.001).
• However, during the 18-month follow-up, CRs were equal for both groups.
• This study highlights the danger of using short-term response to infer long-term outcomes,
especially when a CNI is involved.
• CNIs reduce proteinuria by nonimmune mechanisms and because renal response is largely
determined by improvements in proteinuria, results must be interpreted cautiously.
• This study also raises the question of whether proteinuria should be used as a marker of clinical
response to CNIs
A UR I NI A L L UP US NEP HR I TI S ( A U R A - L V) P HA S E 3 STU DY

• Voclosporin, a novel cyclosporine derivative with a more stable pharmacokinetic profile, plus
SOC (MMF, 2 g/d, with reduced-dose prednisone) will be compared with SOC alone.
• This study is based on a recent phase 2 trial that showed superior 6- and 12-month response
rates with voclosporin plus SOC.
• The positive result is tempered by a higher frequency of adverse events in the voclosporin
group with a significantly higher mortality rate in the low-dose voclosporin group compared
with placebo and high-dose voclosporin (11.2% vs 1.1% and 2.2%, respectively).
• Demonstrating safety in addition to efficacy will be critical to the phase 3 study.
• Finally, repeat kidney biopsies will be done in a subset of patients at the end of this 2-year
study.
• Demonstrating improvement in histologic disease activity with MTT beyond SOC would
provide confidence that CNIs are suppressing autoimmunity and not just masking disease
hemodynamically.
M A NA G EM ENT OF CL A S S V L N

• Immunosuppression –
– with nephrotic-range proteinuria and/or a GFR decline.
– persistent protein excretion > 1 g/d.
– MMF is commonly used as firstline therapy for class V LN but this is more due to familiarity than
superiority over other agents.
• Importantly, the currently available evidence supports the use of MMF, CNIs, or
cyclophosphamide
TRIALS OF ALTERNATIVE DOSING OF CYCLOPHOSPHAMIDE
• Euro-Lupus Nephritis Trial
• RCT
• compared a short-course regimen of low-dose IV CYC to a longer regimen of higher dose IV
CYC as induction treatment of active proliferative LN
• experimental group was given 500 mg of IV CYC every 2 week for 6 doses
• control group was treated with 0.5 gm/m2 IV CYC monthly for 6 doses, f/b 2 additional doses
at 9 mnth and 12 mnth
• In the control group, the dose of CYC was sequentially increased, based on nadir peripheral
blood leukocyte counts, to a maximum of 1500 mg.

• Both groups received pulse methylprednisolone at the start of treatment, f/b tapering doses of
prednisone, and received azathioprine 2 mg/kg daily for maintenance treatment at the end of
the CYC course
• primary endpoint was treatment failure, defined as either persistent renal insufficiency or
nephrotic syndrome, glucocorticoid-resistant flare, or doubling of the S Creat
• Endpoints were assessed in a time to event analysis with a median follow-up 41 months.
• occurrence of the primary endpoint did not differ between treatment groups
• The probability of renal remission (71% versus 54%) and renal flare (27% versus 29%) over
time also did not differ between the low dose and high dose groups.
• 2 patients in the low dose group died and 1 progressed to ESRD, while 2 patients in high dose
group progressed to ESRD.
• Severe infections were more common in the high dose group, while the frequencies of non-
serious infections, leukopenia,and ovarian failure were similar in the two treatment groups
• Conclusion –
• low-dose CYC regimen was comparable in efficacy to a higher dose regimen in patients with
proliferative LN
• low-dose regimen was anticipated to have less toxicity, and was associated with fewer serious
infections, other adverse events were similar between treatment groups
• Myeloablative Regimen

• RCT , compared efficacy of a myeloablative regimen of IV CYC with monthly IV CYC f/b
quarterly infusions for 3 years, following the NIH regimen
• The rationale for testing myeloablative treatment was to attempt to eliminate autoreactive
lymphocytes and re-set the immune system.
• Complete response required a normal serum creatinine, normal creatinine clearance, normal
urinary sediment, and proteinuria <500 mg/day.
• Complete responses were rare at 6 months, but were more common among those treated with
the NIH regimen than with the myeloablative regimen at 30 months
 TR I A L S O F A ZA T H IO P R IN E, C Y CL OS P OR I NE, OR T A CR O L IM U S A S
A L TER NA TI VES T O C Y CL O PH OS P HA M I DE A S I NDU CT I ON T R EA TM ENT

• Dutch Working Party Trial

• randomized trial compared treatment with azathioprine 2 mg/kg daily along with 3 courses of pulse
methylprednisolone to the NIH regimen of IV CYC in patients with proliferative LN
• At entry, 56% of patients had renal impairment and 53% had nephrotic-range proteinuria.
• Over a median follow-up of 5.7 years, 4 times as many patients in the azathioprine group as in the CYC
group met the primary endpoint of doubling of serum creatinine
• Although the likelihood of CR was similar in the two treatment groups over the first 2 years of the study,
relapses were higher in the azathioprine group (7.1 per 100 patient-years versus 1.1 per 100 patient-years).
• Infections, particularly HZ, were more common in the azathioprine group.
• On extended follow-up to a median of 9.6 years, the azathioprine group had numerically higher frequency
of doubling of serum creatinine (16% versus 8%), mortality (16% versus 10%), and renal relapses (38%
versus 10%)
• Although the reports emphasized the lack of significant differences in endpoints other than relapses, the
power of the study to detect differences in other outcomes was limited, and the weight of evidence suggests
greater efficacy for IV CYC compared to azathioprine.
• Trials of Calcineurin Inhibitors
• Chen and colleagues compared outcomes at 6 months between patients with active LN (89%
proliferative; 11% membranous) treated with either tacrolimus (.05 mg/kg daily, titrated to serum
trough levels of 5 to 10 ng/ml) or IV CYC by the NIH regimen in a randomized non-inferiority trial
• 10% of patients had an elevated serum creatinine and 43% had nephrotic-range proteinuria at entry.
• Complete remission at 6 months was seen in 52% of tacrolimus-treated patients and 38% of CYC-
treated patients, with most failures due to persistent proteinuria.
• The study enrolled only one-half of the projected sample size needed to test non-inferiority adequately.
• In a smaller trial of similar design, Li et al reported complete or partial remission in 75% of
tacrolimus-treated patients and 60% of CYC-treated patients at 6 months
• Responses after 9 months of treatment were also similar in a small trial that compared cyclosporine
with intravenous CYC
• Notable in these studies is the rapid improvement in proteinuria and generally good responses
regardless of treatment arm, but their small sizes limit the strength of any comparisons.
• TRIALS OF MYCOPHENOLATE MOFETIL AS INDUCTION TREATMENT
• Seven trials have compared MMF to CYC as induction treatment for LN
• 5 trials included fewer than 50 patients, and 4 of these 5 trials reported similar treatment effects
at 6 months.
• Bao, et al studied combined treated with MMF and tacrolimus Vs IV CYC in patients with
mixed class V and IV LN, and found that combined treatment led to more complete remissions
 ASPREVA LUPUS MANAGEMENT STUDY (ALMS)
• was designed to test if MMF was superior to IV CYC as induction treatment for active LN
• large multi-national study enrolled patients with active, or active and chronic, proliferative or membranous LN.
• Those patients with class III or class V LN were required to have proteinuria of ≥2 gm/day or
• Patients were randomized to open-label MMF with a target dose of 3000 mg daily, or IV CYC by the NIH protocol.
• Patients who worsened over the first 12 weeks of the trial were withdrawn.
• The primary endpoint was renal response, defined as improvement in proteinuria and stabilization or improvement in the serum
creatinine level.
• Mean serum creatinine level at entry was 0.8 mg/dL, and mean UPCR was 4.1.
• 16% patients had membranous LN.
• 83% of the 307 patients completed the 6 month study.
• Most patients in the MMF group took more than 2500 mg daily, and the median CYC dose was 0.75 mg/m2, with a mean number of
infusions per patient of 5.6.
• In contrast to the MMF non-inferiority study, withdrawals were not more frequent in the CYC group.
• Conclusion –
• efficacy and tolerability of MMF and IV CYC over 6 months as induction treatment were similar.
• Given the low proportion of CR, they speculated that longer induction periods may be needed to differentiate between treatments.
• In an interesting sub-analysis, renal responses were substantially more common with MMF treatment than with CYC treatment among
the subgroup of black and Latin patients, while little difference was present among whites or Asians.
• This finding may explain the results favoring MMF in the study by Ginzler et al, which largely included black and Hispanic patients
TR I A L S O F A L TER N A TI VES TO P R OL ONG ED T R EA TM EN T W I T H
CY CL O P H OSP H A M I DE A S M A I NTENA NC E TR EA TM ENT S

• Miami Study
• tested the efficacy of maintenance treatment with either azathioprine or MMF to that of IV CYC given every 3 months
in a randomized trial of patients with proliferative LN who had completed a maximum of 7 monthly infusions with IV
CYC as induction treatment
• The azathioprine group received 1 – 3 mg/kg daily (mean 1 mg/kg), the MMF group received 500 mg to 3000 mg
daily (mean 1500 mg), and the CYC group received 0.5 – 1.0 grams/m2 body surface area (mean 0.55 g/m2).
• Patients also were treated with prednisone up to 0.5 mg/kg daily.
• Maintenance treatments were continued long-term, with median durations of 30 months, 29 months, and 25 months in
the azathioprine, MMF, and CYC groups, respectively
• Patients were predominantly black (45%) or Hispanic (49%) and had severe proliferative LN, with mean serum
creatinine at entry of 1.6 mg/dL, hypertension (97%), and nephrotic syndrome (64%)
• Conclusion –
• maintenance treatment with MMF or azathioprine following induction treatment with IV CYC was superior in both
outcomes and tolerability to continued IV CYC as maintenance treatment.
• This study highlighted the potential for alternative treatments to avoid toxicities associated with prolonged CYC
treatment, and raised the notion that patient ethnicity may influence responses to different treatments.
• However, the mechanisms underlying the poorer response to CYC than to azathioprine or MMF as maintenance
treatment is unclear, given that patients had responded to induction treatment with CYC.
• MAINTAIN
• tested maintenance treatment with either azathioprine or MMF in patients with proliferative LN after
induction treatment with IV CYC using the Euro-Lupus protocol
• Patients entered with active LN (mean serum creatinine 1 mg/dL; 10% with renal insufficiency; 39% with
nephrotic-range proteinuria)
• all were treated with pulse methylprednisolone and 6 infusions of CYC before being randomized to either
azathioprine 2 mg/kg daily or MMF 2000 mg daily, regardless of their response to CYC.
• The primary endpoint was renal flare, defined as either development of nephrotic syndrome, an increase
in serum creatinine, or an increase in proteinuria accompanied by hematuria and depression of C3 levels.
• Conclusion –
• there was insufficient evidence to support superiority.
• In contrast to the ALMS, treatments were open-label rather than blinded, and patients were not enrolled
based on their response to induction treatment.
• The primary outcome was also more focused in MAINTAIN, which may have lessened the opportunity to
detect differences between treatment groups, as would the smaller sample.
• The ethnic composition of the study group might have also affected assessment of the relative efficacy of
these two medications, if MMF has particular benefit in ethnic minorities
• Cyclosporine versus Azathioprine
• Moroni and colleagues compared cyclosporine 4 mg/kg daily to azathioprine 2 mg/kg daily as
maintenance treatment for patients with proliferative LN after induction treatment with pulse
methylprednisolone and oral CYC 1 – 2 mg/kg daily for 3 months
• 7 renal flares, either proteinuric or nephritic (with an increase in serum creatinine level),
occurred in the cyclosporine group, for a rate of 10.6 flares per 100 patient-years of treatment,
while 8 renal flares occurred in the azathioprine group, for a rate of 13.4 flares per 100 patient
years.
• Improvements in serum creatinine levels and proteinuria were similar in the two groups, but
comparisons were hampered by the small sample.
TRIAL OF RITUXIMAB

• LUNAR (Lupus Nephritis Assessment with Rituximab)

• Randomized placebo-controlled trial designed to test whether treatment with rituximab could boost complete renal
responses among patients with active LN when added to other immunosuppressive treatments
• This study was motivated by the suboptimal rates of complete responses to induction treatment seen with MMF or
intravenous CYC in patients with active proliferative LN.
• In this trial all patients were started on induction treatment with MMF 3000 mg daily and pulse methylprednisolone.
In addition, blinded treatment with rituximab (1 g) or placebo was given on days 1, 15, 168 and 182 of treatment,
with 72 patients in each group.
• The primary outcome was complete renal response, defined as normalization or stabilization of the serum creatinine
level, and normalization of the urinary sediment and proteinuria.
• Rituximab was effective in B cell depletion.
• At 52 weeks, 26.4% of patients in the rituximab group had complete renal response, compared to 30.6% in the
placebo group.
• Partial responses were numerically higher in the rituximab group, and serological parameters improved more in this
group, but other renal responses did not differ.
• Two deaths occurred in the rituximab group, while the risks of other adverse events, including serious infections,
were not different between treatment groups.
• this study demonstrated lack of benefit from rituximab when added to a regimen of MMF and
corticosteroids for induction treatment.
• The study was not designed to test if rituximab could be an acceptable replacement for other
induction medications, nor if the use of rituximab would permit more rapid tapering of
corticosteroids or reduced doses of MMF without worsening control of LN
• Combining rituximab with MMF did not result in additional safety concerns
TR I A L S I N M EM B R A NOU S L UP US NEP R H IT I S

• Membranous LN has commonly been treated with alternate-day corticosteroids, although

• studies have also investigated the effectiveness of cyclosporine, tacrolimus, MMF, and
• CYC. Austin, et al performed an open-label randomized trial comparing cyclosporine 200
• mg/m2 daily and high-dose alternate-day prednisone, intravenous CYC 0.5 – 1.0 g/m2 every
• other month for 6 infusions and high-dose alternate-day prednisone, and high-dose alternateday
• prednisone alone in 42 patients with membranous LN and proteinuria of at least 2 g
• daily (median 5.4 g daily) [49]. At 12 months, remission was present in 83% of patients
• treated with cyclosporine, 60% treated with CYC, and 27% treated with prednisone alone.
• Patients in the cyclosporine group responded more rapidly, but were also more likely to
• relapse on discontinuation of treatment than those treated with CYC. However, either
• medication provided better short-term control of proteinuria than corticosteroids alone
PREGNANCY AND LN

• counseled to wait until LN is quiescent for at least 6 months.

• switch to a “pregnancy friendly” regimen at least 3 months before attempting conception
• Patients taking MMF should be switched to azathioprine.
• CNIs can be continued throughout pregnancy.
• safety of rituximab - not very well established but the manufacturer’s label warns against
conception for a year after rituximab use
• Tapering immunosuppressive therapy and attempting to conceive at the same time is strongly discouraged because
getting pregnant with active disease has deleterious consequences.
• However, >80% of pregnancies in patients without active LN or extrarenal lupus activity are uncomplicated.
• A prospective cohort study of 71 pregnancies in patients with mostly quiescent LN, optimally managed with
prepregnancy counseling by a multidisciplinary team, found that LN flares occurred in 20% of patients;
preeclampsia or HELLP (hemolysis, elevated liver enzyme levels, and a low platelet count) syndrome, in 11%;
fetal loss, in 8.4%; and preterm birth, in 30.8%.
• In comparison, the fetal loss rate after 20 weeks of gestation in the general US population is reported to be 6 in
1,000 live births and preterm birth occurs in ~10% of pregnancies.
• Treating a renal flare in pregnant patients can be challenging.
• A kidney biopsy may be needed to establish the diagnosis and can be performed safely up to 20 weeks
of gestation.
• Therapeutic options are limited and include hydroxychloroquine, corticosteroids, azathioprine, CNIs,
and IV immune globulin.
• The authors typically use a multitargeted regimen of azathioprine and CNIs that are combined with
steroids.
• IV immune globulin is reserved for resistant and/or severe cases.
• HCQ should be used in all pregnant patients with SLE unless contraindicated. HCQ use has been
shown to reduce the probability of having a small-for-gestational age baby by 85% and reduces the risk
for congenital heart block by 50% in babies of mothers who are anti-Ro antibody positive.
• In addition to HCQ, treatment with azathioprine and/or a CNI may most effectively treat LN and is
recommended as a first-line treatment option in the setting of renal flare during pregnancy.
• Corticosteroids, while effective, increase the risk for gestational diabetes and use should be limited if
possible.
DIALYSIS AND TRANSPLANTATION IN LN
• Patients with LN treated with dialysis have comparable 5-year survival rates as patients without LN receiving dialysis
• Patients with LN who receive a kidney transplant have better survival and fewer cardiovascular and infectious
complications than patients with LN receiving dialysis. In one study of mortality and KRT, about 32 events per 1,000
patient-years occurred in 946 patients with LN who underwent transplantation
• compared with about 257 events per 1,000 patient-years in 3,431 patients with LN receiving dialysis.
• Conventional wisdom has suggested that patients with LN receive several (3-6) months of dialysis before a kidney
transplant to ensure disease quiescence.
• However, a study of more than 4,700 patients with LN showed that a wait time on dialysis of more than 3 months was
associated with 2-fold increased risk for graft failure compared with those with fewer than 3 months receiving dialysis.
• Patients with LN who underwent preemptive transplantation had superior allograft and overall survival and did not have
increased risk for recurrent LN post transplantation.
• LN may recur in kidney allografts with an estimated incidence of 2% to 11% after a median duration of 4 years
• Recurrence is most commonly class II LN, and although recurrence increases risk, graft loss is rare and patient and
allograft survival are similar in patients with and without LN.
• Antiphospholipid syndrome increases the risk for allograft loss and because it occurs frequently in LN, it should be
screened for before transplantation.
IM P R OVI NG OUT CO M ES I N L N
• Minimizing LN flares and early identification of flare
• combining clinical data with molecular and genetic data from the individual
• efforts are underway to add more information to the histology of the kidney biopsy through
“omic” analyses of kidney tissue and to identify biomarkers of active pathogenic pathways in
serum and urine of patients with SLE and LN
ONG OI NG T R I A L FOR L N
• Safety and Efficacy of Filgotinib and Lanraplenib in Adults With Lupus Membranous
Nephropathy (LMN)
AURINIA RENAL ASSESSMENTS 2: AURINIA RENAL RESPONSE IN LUPUS
WITH VOCLOSPORIN (AURORA2)