The 2024 APLAR Consensus on the Management of Lupus Nephritis

The APLAR has published a set of recommendations on the management of systemic lupus erythematosus (SLE) in 2021. The current consensus paper supplements and updates specifically the treatment of lupus nephritis (LN) according to two rounds of Delphi exercise from members of the APLAR SLE special interest group, invited nephrologists, histopathologists, and lupus nephritis patients. For initial treatment of LN, we recommend a combination of glucocorticoids (GCs) with cyclophosphamide (CYC), mycophenolate mofetil (MMF), or the calcineurin inhibitors (CNIs) as first-line options. An upfront combination of immunosuppressive drugs and the biological agents may be considered in patients at significant risk of disease progression and renal function deterioration. Switching or "add-on" among different immunosuppressive agents, including biological agents, may be considered for refractory disease. Subsequent/maintenance therapy of LN should continue for at least 3 years to reduce the risk of renal flares. Lower dose MMF and azathioprine are options, but MMF maintenance should follow induction by the same drug. Prednisolone or equivalent should be maintained at a dose of 5 mg/day or less. The APLAR consensus for the management of LN includes recommendations for adjunctive therapies, monitoring and treatment of LN-related co-morbidities, and renal replacement therapies. It is hoped that this consensus paper can provide an evidence-based and pragmatic approach to the management of LN, taking into account the evidence level of therapies in Asian patients, cost-effectiveness, and differences in health care resources and reimbursement policies in the Asia-Pacific region.