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Nephritis

Last edited: 4/13/2026

Overview

Lupus nephritis (LN) is an inflammatory condition characterized by immune complex deposition in the kidney, leading to glomerular damage and potential renal failure in patients with systemic lupus erythematosus (SLE). 147

Diagnosis

  • Histopathological Grading: Utilize the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification system for staging LN (Classes I-VI). 193950
  • Biomarkers: Consider biomarkers for monitoring disease activity and response to therapy, though specific biomarkers are still under investigation. 1
  • Renal Function Tests: Assess proteinuria, serum creatinine, and estimated glomerular filtration rate (eGFR). 115
  • Imaging: Ultrasound or renal biopsy may be necessary for definitive diagnosis and staging. 49

    • Management

  • First-Line Treatments:
    • - Immunosuppressive Agents: Mycophenolate mofetil (MMF), cyclophosphamide, or tacrolimus. 7202133 - Corticosteroids: High-dose glucocorticoids for induction therapy, often tapered based on response. 21533
  • Adjunctive Therapies:
    • - Calcineurin Inhibitors: Voclosporin has shown efficacy and safety in clinical trials. 311122133 - Biologics: Obinutuzumab and belimumab have demonstrated efficacy in specific trials. 6282936 - Multitarget Therapy: Combination regimens like rituximab plus cyclophosphamide followed by belimumab. 34

    Special Populations

  • Pregnancy: LN generally remains quiescent during pregnancy if disease is stable; careful monitoring is essential. 59
  • Pediatrics: Specific treatment protocols exist, emphasizing standardized induction therapy to reduce variability. 2222
  • Elderly: Tailored immunosuppressive strategies considering comorbidities and renal function; close monitoring is crucial. 7

    • Key Recommendations

  • Induction Therapy: Use MMF or tacrolimus with high-dose glucocorticoids for initial treatment (Evidence: Strong 720).
  • Maintenance Therapy: Transition to maintenance therapy with MMF or calcineurin inhibitors like voclosporin post-induction, based on response and renal function (Evidence: Moderate 22133).
  • Monitoring and Biopsy: Consider repeat renal biopsies to guide therapy adjustments in patients with persistent or recurrent disease (Evidence: Expert opinion 841).
  • Safety Monitoring: Regularly assess for adverse events, particularly with calcineurin inhibitors like voclosporin, using real-world safety databases (Evidence: Moderate 31112).
  • Personalized Approach: Tailor immunosuppressive withdrawal strategies based on individual patient response and disease activity (Evidence: Moderate 8).

    • References

    1 Querin V, Palazzo L, Fogo AB, Haas M, Jayne DRW, Lightstone L et al.. Biomarkers of Lupus Nephritis Histopathology: Where Do We Stand?. Arthritis & rheumatology (Hoboken, N.J.) 2026. link 2 Aljohani R, Alenzi F, Allem A, Aljabri J, Alharbi S. Tapering strategies for immunosuppressive, corticosteroid, and biologic therapy in lupus nephritis: a national survey of rheumatology and nephrology practices in Saudi Arabia. Rheumatology international 2026. link 3 Zhang J, Wan Y, Liu L, Chen R, Shi Y, Tang Y et al.. Clinical adverse events to voclosporin: a real-world drug safety study based on the FDA Adverse Event Reporting System. Clinical and experimental rheumatology 2026. link 4 Sammaritano LR, Askanase A, Bermas BL, Dall'Era M, Duarte-García A, Hiraki LT et al.. 2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis. Arthritis & rheumatology (Hoboken, N.J.) 2025. link 5 Sammaritano LR, Askanase A, Bermas BL, Dall'Era M, Duarte-García A, Hiraki LT et al.. 2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis. Arthritis care & research 2025. link 6 Furie RA, Rovin BH, Garg JP, Santiago MB, Aroca-Martínez G, Zuta Santillán AE et al.. Efficacy and Safety of Obinutuzumab in Active Lupus Nephritis. The New England journal of medicine 2025. link 7 Dong Z, Luo P, Sun S, Ni Z, He Y, Huang X et al.. Mizoribine or Cyclophosphamide for Lupus Nephritis: A Randomized Clinical Trial. JAMA network open 2025. link 8 Kandinata SG, Awalia, Yuliasih, Rahmawati LD, Nugroho CW, Putri AT et al.. Immunosuppressive therapy withdrawal in lupus nephritis, is it possible?: A systematic review. Lupus 2025. link 9 Macía M, Fernández-Juárez G, Ávila AI, Espino M, Espinosa M, Fulladosa X et al.. GLANCE survey: awareness and implementation of the GLOSEN recommendations for the diagnosis and treatment of lupus nephritis. Nefrologia 2025. link 10 Mok CC, So H, Hamijoyo L, Kasitanon N, Chen Y, Bae SC et al.. The 2024 APLAR Consensus on the Management of Lupus Nephritis. International journal of rheumatic diseases 2025. link 11 Chen M, Huang Y, Ke C, Chen M. Safety assessment of voclosporin: a real-world disproportionality analysis of the FAERS database. Immunopharmacology and immunotoxicology 2025. link 12 Gu B, Lv B, Tang J. Phase IV safety evaluation of voclosporin in lupus nephritis patients using the FAERS database for a 42-month period (2021 - 2024). International journal of clinical pharmacology and therapeutics 2025. link 13 Tian GQ, Li ZQ. Efficacy and safety of biologics, multitarget therapy, and standard therapy for lupus nephritis: a systematic review and network meta-analysis. Renal failure 2024. link 14 Dall'Era M, Kalunian K, Solomons N, Truman M, Hodge LS, Yap E et al.. Comparison of a voclosporin-based triple immunosuppressive therapy to high-dose glucocorticoid-based immunosuppressive therapy: a propensity analysis of the AURA-LV and AURORA 1 studies and ALMS. Lupus science & medicine 2024. link 15 Figueroa-Parra G, Cuéllar-Gutiérrez MC, González-Treviño M, Sanchez-Rodriguez A, Flores-Gouyonnet J, Meade-Aguilar JA et al.. Impact of Glucocorticoid Dose on Complete Response, Serious Infections, and Mortality During the Initial Therapy of Lupus Nephritis: A Systematic Review and Meta-Analysis of the Control Arms of Randomized Controlled Trials. Arthritis & rheumatology (Hoboken, N.J.) 2024. link 16 Menn-Josephy H, Hodge LS, Birardi V, Leher H. Efficacy of Voclosporin in Proliferative Lupus Nephritis with High Levels of Proteinuria. Clinical journal of the American Society of Nephrology : CJASN 2024. link 17 Liu X, Chen X, Yang C, Li R, Chen X, Li Q. Biologicals for the treatment of lupus nephritis: a Bayesian network meta-regression analysis. Frontiers in immunology 2024. link 18 Rovin BH, Furie RA, Ross Terres JA, Giang S, Schindler T, Turchetta A et al.. Kidney Outcomes and Preservation of Kidney Function With Obinutuzumab in Patients With Lupus Nephritis: A Post Hoc Analysis of the NOBILITY Trial. Arthritis & rheumatology (Hoboken, N.J.) 2024. link 19 Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Balk EM et al.. Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus Nephritis. Kidney international 2024. link 20 Jiang N, Jin S, Yu C, Zhao J, Wang Q, Tian X et al.. Efficacy and safety of immunosuppressive agents for adults with lupus nephritis: a systematic review and network meta-analysis. Frontiers in immunology 2023. link 21 Arriens C, Teng YKO, Ginzler EM, Parikh SV, Askanase AD, Saxena A et al.. Update on the Efficacy and Safety Profile of Voclosporin: An Integrated Analysis of Clinical Trials in Lupus Nephritis. Arthritis care & research 2023. link 22 Jayne D, Rovin B, Mysler E, Furie R, Houssiau F, Trasieva T et al.. Anifrolumab in lupus nephritis: results from second-year extension of a randomised phase II trial. Lupus science & medicine 2023. link 23 Anders HJ, Furie R, Malvar A, Zhao MH, Hiromura K, Weinmann-Menke J et al.. Effect of belimumab on kidney-related outcomes in patients with lupus nephritis: post hoc subgroup analyses of the phase 3 BLISS-LN trial. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2023. link 24 Wang A, Zhao J, Qin Y, Zhang Y, Xing Y, Wang Y et al.. Alterations of the gut microbiota in the lupus nephritis: a systematic review. Renal failure 2023. link 25 Wei Q, Yan Q, Zhang S, Gao F, Chen Z, Lin H et al.. Mitochondrial Dynamics of Podocyte in Various International Society of Nephrology/Renal Pathology Society Class Lupus Nephritis Patients. DNA and cell biology 2023. link 26 Stotter BR, Cody E, Gu H, Daga A, Greenbaum LA, Duong MD et al.. Acute kidney injury requiring kidney replacement therapy in childhood lupus nephritis: a cohort study of the Pediatric Nephrology Research Consortium and Childhood Arthritis and Rheumatology Research Alliance. Pediatric nephrology (Berlin, Germany) 2023. link 27 Furie RA, Aroca G, Cascino MD, Garg JP, Rovin BH, Alvarez A et al.. B-cell depletion with obinutuzumab for the treatment of proliferative lupus nephritis: a randomised, double-blind, placebo-controlled trial. Annals of the rheumatic diseases 2022. link 28 Furie R, Rovin BH, Houssiau F, Contreras G, Teng YKO, Curtis P et al.. Safety and Efficacy of Belimumab in Patients with Lupus Nephritis: Open-Label Extension of BLISS-LN Study. Clinical journal of the American Society of Nephrology : CJASN 2022. link 29 Rovin BH, Furie R, Teng YKO, Contreras G, Malvar A, Yu X et al.. A secondary analysis of the Belimumab International Study in Lupus Nephritis trial examined effects of belimumab on kidney outcomes and preservation of kidney function in patients with lupus nephritis. Kidney international 2022. link 30 Jayne D, Rovin B, Mysler EF, Furie RA, Houssiau FA, Trasieva T et al.. Phase II randomised trial of type I interferon inhibitor anifrolumab in patients with active lupus nephritis. Annals of the rheumatic diseases 2022. link 31 Fu Q, Wu C, Dai M, Wang S, Xu J, Dai L et al.. Leflunomide versus azathioprine for maintenance therapy of lupus nephritis: a prospective, multicentre, randomised trial and long-term follow-up. Annals of the rheumatic diseases 2022. link 32 Patel P, de Guzman M, Hicks MJ, Maliakkal JG, Rheault MN, Selewski DT et al.. Utility of the 2018 revised ISN/RPS thresholds for glomerular crescents in childhood-onset lupus nephritis: a Pediatric Nephrology Research Consortium study. Pediatric nephrology (Berlin, Germany) 2022. link 33 Rovin BH, Teng YKO, Ginzler EM, Arriens C, Caster DJ, Romero-Diaz J et al.. Efficacy and safety of voclosporin versus placebo for lupus nephritis (AURORA 1): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet (London, England) 2021. link00578-X) 34 Atisha-Fregoso Y, Malkiel S, Harris KM, Byron M, Ding L, Kanaparthi S et al.. Phase II Randomized Trial of Rituximab Plus Cyclophosphamide Followed by Belimumab for the Treatment of Lupus Nephritis. Arthritis & rheumatology (Hoboken, N.J.) 2021. link 35 Chen X, Wang DD, Li ZP. Analysis of time course and dose effect of tacrolimus on proteinuria in lupus nephritis patients. Journal of clinical pharmacy and therapeutics 2021. link 36 Tanabe K, Matsuoka-Uchiyama N, Mifune T, Kawakita C, Sugiyama H, Wada J. Management of corticosteroid-dependent eosinophilic interstitial nephritis: A case report. Medicine 2021. link 37 Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I et al.. 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Annals of the rheumatic diseases 2020. link 38 Jayne D, Bajema IM. "In my beginning is my end": usefulness of repeat kidney biopsies in lupus nephritis. Kidney international 2020. link 39 Umeda R, Ogata S, Hara S, Takahashi K, Inaguma D, Hasegawa M et al.. Comparison of the 2018 and 2003 International Society of Nephrology/Renal Pathology Society classification in terms of renal prognosis in patients of lupus nephritis: a retrospective cohort study. 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    Original source

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      Biomarkers of Lupus Nephritis Histopathology: Where Do We Stand? — Querin V, Palazzo L, Fogo AB, Haas M, Jayne DRW, Lightstone L et al. Arthritis & rheumatology (Hoboken, N.J.) (2026)
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      Tapering strategies for immunosuppressive, corticosteroid, and biologic therapy in lupus nephritis: a national survey of rheumatology and nephrology practices in Saudi Arabia. — Aljohani R, Alenzi F, Allem A, Aljabri J, Alharbi S Rheumatology international (2026)
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      Clinical adverse events to voclosporin: a real-world drug safety study based on the FDA Adverse Event Reporting System. — Zhang J, Wan Y, Liu L, Chen R, Shi Y, Tang Y et al. Clinical and experimental rheumatology (2026)
    4. [4]
      2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis. — Sammaritano LR, Askanase A, Bermas BL, Dall'Era M, Duarte-García A, Hiraki LT et al. Arthritis & rheumatology (Hoboken, N.J.) (2025)
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      2024 American College of Rheumatology (ACR) Guideline for the Screening, Treatment, and Management of Lupus Nephritis. — Sammaritano LR, Askanase A, Bermas BL, Dall'Era M, Duarte-García A, Hiraki LT et al. Arthritis care & research (2025)
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      Efficacy and Safety of Obinutuzumab in Active Lupus Nephritis. — Furie RA, Rovin BH, Garg JP, Santiago MB, Aroca-Martínez G, Zuta Santillán AE et al. The New England journal of medicine (2025)
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      Mizoribine or Cyclophosphamide for Lupus Nephritis: A Randomized Clinical Trial. — Dong Z, Luo P, Sun S, Ni Z, He Y, Huang X et al. JAMA network open (2025)
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      Immunosuppressive therapy withdrawal in lupus nephritis, is it possible?: A systematic review. — Kandinata SG, Awalia, Yuliasih, Rahmawati LD, Nugroho CW, Putri AT et al. Lupus (2025)
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      GLANCE survey: awareness and implementation of the GLOSEN recommendations for the diagnosis and treatment of lupus nephritis. — Macía M, Fernández-Juárez G, Ávila AI, Espino M, Espinosa M, Fulladosa X et al. Nefrologia (2025)
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      Impact of Glucocorticoid Dose on Complete Response, Serious Infections, and Mortality During the Initial Therapy of Lupus Nephritis: A Systematic Review and Meta-Analysis of the Control Arms of Randomized Controlled Trials. — Figueroa-Parra G, Cuéllar-Gutiérrez MC, González-Treviño M, Sanchez-Rodriguez A, Flores-Gouyonnet J, Meade-Aguilar JA et al. Arthritis & rheumatology (Hoboken, N.J.) (2024)
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