The American College of Rheumatology (ACR) recently released new clinical practice guidelines for lupus nephritis (LN). This is the first update from the ACR on this condition in over 10 years. Since that time there have been new FDA approved treatments for LN. This has led to a fundamental change in treatment, with a departure from initiation and maintenance therapy to continuous combination immunosuppressive therapy targeting different parts of the immune system. 

In this discussion, we will explore some of the major changes and key takeaways in the treatment of lupus nephritis.

Guidelines Referenced:

  • 2024 Screening, Treatment, and Management of Lupus Nephritis
  • 2012 Screening, Treatment, and Management of Lupus Nephritis

Major Changes and Key Takeaways (2012-2025):

Since 2012 there have been major changes to the treatment of LN. Below we will highlight some of those important changes. 

  • Combination therapy
    • The previously used initiation and maintenance therapies have been replaced by continuous and ongoing combination triple immunosuppressive therapies targeting different parts of the immune system. 
  • Glucocorticoids
    • Specific recommendations for glucocorticoid tapering were included in the 2025 ACR guidelines.
  • FDA approved drugs for the treatment of LN since the last guideline include:
    • Belimumab
      • A biologic that may be used as part of a triple immunosuppressive therapy regimen for class III, IV, and V LN
    • Voclosporin
      • A calcineurin inhibitor that may be used as part of a triple immunosuppressive therapy regimen for class III, IV, and V LN.
  • Duration of therapy
    • New recommendations include advice on the total duration of treatment:
      • 3 to 5 years for patients who achieve a complete renal response.
  • Renal replacement therapy
    • New recommendations include advice for renal replacement therapy, favoring kidney transplant over dialysis for most patients with, or nearing, end-stage kidney disease.

In summary, the ACRs updated practice guidelines offer newer evidence-based triple immunosuppressive treatment regimens and advice on renal replacement therapies with the goal of preserving kidney function and improving overall health and quality of life in patients with LN.

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