The treatment of severe lupus nephritis

Summary: The treatment of lupus nephritis involves two distinct phases of management: (i) induction therapy of acute severe disease; and (ii) maintenance treatment of chronic, sometimes relapsing disease. Since the introduction of effective immunosuppression, first with corticosteroids and then with cytotoxic agents in addition, the prognosis for lupus nephritis has improved greatly, especially that of more severe disease, whose prognosis now matches that of milder forms. There is now good evidence that the addition of a cytotoxic agent to corticosteroids improves both histological evolution and the development of renal failure, but both the choice of cytotoxic agent and the route of administrations remain controversial. Although the use of intravenous cyclophosphamide at intervals is popular, the long term outcome using azathioprine is as good and the drug is less toxic, particularly in relation to gonadal function and pregnancy. Therefore, we prefer to use induction with oral cyclophosphamide for 12 weeks, followed by azathiorpine therapy. the dose and route of corticosteroid in the acute phase is likewise controversial: high dose intravenous methylprednisolone perhaps has the advantage of lower side‐effects than high dose oral corticosteroids. Controlled trials of plasma exchange have so far failed to reveal any benefits in the acute phase of lupus. Newer forms of immunosuppression using biological reagents against the immune reaction show promise, but their use is still experimental.