Belimumab for the treatment of refractory lupus nephritis: Real-word experience from three clinical cases

Belimumab is a U.S. Food and Drug Administration (FDA) approved treatment for patients aged ≥5 years with active systemic lupus erythematosus (SLE) or lupus nephritis (LN) who are receiving standard therapy.¹ Approval in LN was based on the positive results from the BLISS-LN trial, previously reported on the Lupus Hub, which examined belimumab alongside standard-of-care therapy (glucocorticoids, with mycophenolate mofetil or cyclophosphamide-azathioprine) in patients with class III/IV/V LN. The trial did not include patients for whom conventional therapies failed to yield a response.²

Below, we summarize a case series accessing efficacy and safety of belimumab in three patients with refractory LN, published by Malaweera et al. in Internal Medical Journal.²

Study design²

A retrospective review of longitudinal data included in the Australian Lupus Registry and Biobank (ALRB) between 2010 and 2021 for three identified patients treated with belimumab for refractory LN. With their informed consent, baseline demographic and clinical information was obtained. Belimumab (10 mg/kg) was administered intravenously on Days 0, 14, 38, and monthly thereafter.

Key findings

An overview of the three patient cases is shown in Figure 1.

AZA, azathioprine; CRR, complete renal response; CsA, cyclosporine; CTC, cyclophosphamide; CYC, cyclophosphamide; ds, double stranded; GC, glucocorticoid; HCQ, hydroxychloroquine; LN, lupus nephritis; MMF, mycophenolate mofetil; PRR, partial renal response; PSL, prednisolone; RTX, rituximab; SLE, systemic lupus erythematosus; TAC, tacrolimus.
*Data from Malaweera, et al.¹

Key learnings

Belimumab was beneficial in two of three patients with refractory LN, but complete renal remission was not achieved. Cases 1 and 2 achieved a partial renal remission, with ongoing proteinuria, possibly due to irreversible chronic kidney damage prior to belimumab initiation. Patient 3 had significant chronic damage while initiating belimumab and progressed to end-stage renal failure despite belimumab therapy. Belimumab treatment was well tolerated and led to a reduction in glucocorticoid dose for two patients; an important outcome given the role of glucocorticoids in SLE-related organ damage.