Multidisciplinary approach to lupus nephritis: Clinical pearls, pitfalls, and positioning of newly-approved agents

Renal biopsy is indispensable for the management of lupus nephritis (LN).

New-onset LN: belimumab may be added from disease onset; patients with moderate to severe proliferative nephritis (NIH activity index > 5 plus ≥ 1 of: NIH chronicity index > 2, proteinuria > 3 g/24 h, increase in serum creatinine > 20%) may be more likely to benefit the most.

Patients already on standard of care (mycophenolate mofetil (MMF) or CYC): belimumab could be considered with inadequate clinical response by 3 months, nephritic flare after initial response, or inability to reduce GC dose.

Belimumab should always be given as add-on therapy, combined with standard of care (MMF or CYC).

Voclosporin could be considered for up to 3 years, with MMF, in heavy proteinuria (well above nephrotic range) where quick reduction of proteinuria is desirable, as initial regimen or with inadequate proteinuria reduction on MMF.

Given potential scarring effects, long-term administration beyond the first year requires further documentation.