Management of lupus nephritis: ACR 2024 guidelines

The ACR issued evidence-based expert guidance for the screening, treatment, and management of LN in adults and children with SLE. The guidelines comprise 28 graded recommendations (7 strong and 21 conditional) and 13 ungraded consensus-based GPSs.¹ We summarize the key recommendations and GPSs, highlighting the importance of prompt kidney biopsy and appropriate LN treatment.

Strong recommendations:

• Screening for proteinuria at least every 6–12 months or while experiencing extrarenal flares for patients with SLE without known kidney disease.
• Proteinuria monitoring at least every 3 months for patients with LN without CRR, and every 3–6 months in those with sustained CRR.

Conditional recommendation for patients with active/ND/flare of Class III/IV ± V to be treated with triple immunosuppressive therapy:

• GCs (pulse IV 250–1,000 mg MP QD for 1–3 days followed by oral GCs ≤0.5 mg/kg/day [max dose 40 mg/day] with taper to a target dose of ≤5 mg/day by 6 months) combined with MPAA + belimumab.
• Or MPAA + CNI, or ELNT low-dose CYC + belimumab, with a total therapy duration of ≤3–5 years after achieving/sustaining CRR. MPAA-based regimen is preferred over CYC-based.