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Kidney biopsy shows one of six histologic patterns
Class I: minimal mesangial nephritis
Class II: mesangial proliferative
Class III: focal (< 50% of glomeruli affected with capillary involvement) proliferative
Class IV: diffuse (> 50% of glomeruli affected with capillary involvement) proliferative
Class V: membranous nephropathy
Class VI: advanced sclerosis without residual disease activity
Class III and IV, the most severe forms of proliferative lupus nephritis, are further classified as active or chronic, and global or segmental, which confers additional prognostic value
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No treatment required for classes I and II
Corticosteroids should be considered for those with class II lesions with nephrotic-range proteinuria
Aggressive immunosuppressive therapy for extensive class III lesions and all class IV lesions
Immunosuppressive therapy for class V lupus nephritis is indicated if superimposed proliferative lesions exist
Class VI lesions should not be treated
Corticosteroids: methylprednisolone, 1 g once daily for 3 days intravenously, followed by prednisone, 1 mg/kg once daily orally with subsequent taper for 6–12 months
Cyclophosphamide induction regimens
Vary, but usually involve monthly intravenous pulse doses (500–1000 mg/m2) for 6 months
Induction is followed by daily oral mycophenolate mofetil or azathioprine maintenance therapy
Cyclosporine or tacrolimus may be considered, but relapse is high upon discontinuation
Mycophenolate mofetil
Typically given at 2–3 g orally daily, then tapered to 1–2 g/day for maintenance
Has a more favorable side-effect profile than does cyclophosphamide
Should be favored when preservation of fertility is a consideration
Rituximab
Was used in addition to corticosteroids and mycophenolate mofetil for class III/IV LN induction therapy in a recent clinical trial but did not show significant renal improvement over placebo at 1 year
Remission rates with induction vary from 80% for partial remission to 50–60% for full remission
Relapse is common and rates of disease flare are higher in those who do not experience complete remission
Monitoring dsDNA antibodies; C3, C4, and CH50; urinary protein; and urine sediment activity can be useful during treatment
Patients with SLE undergoing kidney transplants can have recurrent kidney disease, although rates are relatively low