Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece
Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
RMD Open. 2020 Jul;6(2). doi: 10.1136/rmdopen-2020-001263.
To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations.
According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012.
We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500-700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b).
There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.
分析目前狼疮肾炎（LN）管理的证据，为 2019 年 EULAR/欧洲肾脏协会-欧洲透析与移植协会建议的更新提供信息。
根据 EULAR 标准化操作程序，从 2012 年 1 月 1 日至 2018 年 12 月 31 日，进行了 PubMed 系统文献回顾。由于这是对 2012 年建议的更新，最终证据水平（LoE）和推荐等级考虑了包括 2012 年前文献在内的整体证据。
我们确定了 387 篇相关文章。高质量随机证据支持免疫抑制治疗用于 III 类和 IV 类 LN（LoE 1a），中等质量证据支持免疫抑制治疗用于具有肾病范围蛋白尿的单纯 V 类 LN（LoE 2b）。治疗的目标应是在 3 个月时蛋白尿减少至少 25%，6 个月时减少 50%，12 个月时完全肾脏应答（<500-700mg/天）（LoE 2a-2b）。高质量证据支持在活动期 III/IV 类 LN 中使用霉酚酸酯/霉酚酸（MMF/MPA）或低剂量静脉环磷酰胺（CY）作为初始治疗（LoE 1a）。在特定情况下，他克莫司联合 MMF/MPA 和高剂量 CY 是替代方法（LoE 1a）。有低质量证据指导 LN 中免疫抑制的最佳持续时间（LoE 3）。在终末期肾病中，可以使用所有肾脏替代治疗方法，其中移植具有最有利的结果（LoE 2b）。
有高质量证据指导 III/IV 类 LN 的初始和后续治疗阶段，但有低至中等质量证据指导 V 类 LN、监测和免疫抑制的最佳持续时间。
