Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil.
Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
Adv Rheumatol. 2024 Jun 18;64(1):48. doi: 10.1186/s42358-024-00386-8.
To develop the second evidence-based Brazilian Society of Rheumatology consensus for diagnosis and treatment of lupus nephritis (LN).
Two methodologists and 20 rheumatologists from Lupus Comittee of Brazilian Society of Rheumatology participate in the development of this guideline. Fourteen PICO questions were defined and a systematic review was performed. Eligible randomized controlled trials were analyzed regarding complete renal remission, partial renal remission, serum creatinine, proteinuria, serum creatinine doubling, progression to end-stage renal disease, renal relapse, and severe adverse events (infections and mortality). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to develop these recommendations. Recommendations required ≥82% of agreement among the voting members and were classified as strongly in favor, weakly in favor, conditional, weakly against or strongly against a particular intervention. Other aspects of LN management (diagnosis, general principles of treatment, treatment of comorbidities and refractory cases) were evaluated through literature review and expert opinion.
All SLE patients should undergo creatinine and urinalysis tests to assess renal involvement. Kidney biopsy is considered the gold standard for diagnosing LN but, if it is not available or there is a contraindication to the procedure, therapeutic decisions should be based on clinical and laboratory parameters. Fourteen recommendations were developed. Target Renal response (TRR) was defined as improvement or maintenance of renal function (±10% at baseline of treatment) combined with a decrease in 24-h proteinuria or 24-h UPCR of 25% at 3 months, a decrease of 50% at 6 months, and proteinuria < 0.8 g/24 h at 12 months. Hydroxychloroquine should be prescribed to all SLE patients, except in cases of contraindication. Glucocorticoids should be used at the lowest dose and for the minimal necessary period. In class III or IV (±V), mycophenolate (MMF), cyclophosphamide, MMF plus tacrolimus (TAC), MMF plus belimumab or TAC can be used as induction therapy. For maintenance therapy, MMF or azathioprine (AZA) are the first choice and TAC or cyclosporin or leflunomide can be used in patients who cannot use MMF or AZA. Rituximab can be prescribed in cases of refractory disease. In cases of failure in achieving TRR, it is important to assess adherence, immunosuppressant dosage, adjuvant therapy, comorbidities, and consider biopsy/rebiopsy.
This consensus provides evidence-based data to guide LN diagnosis and treatment, supporting the development of public and supplementary health policies in Brazil.
制定巴西风湿病学会第二版狼疮肾炎（LN）诊断和治疗的循证共识。
两名方法学家和 20 名来自巴西风湿病学会狼疮委员会的风湿病专家参与了本指南的制定。定义了 14 个 PICO 问题，并进行了系统评价。对符合完全缓解、部分缓解、血肌酐、蛋白尿、血肌酐加倍、进展为终末期肾病、肾脏复发和严重不良事件（感染和死亡率）的随机对照试验进行了分析。采用推荐评估、制定和评估（GRADE）方法制定这些建议。建议需要投票成员中≥82%的一致性，并分类为强烈赞成、弱赞成、有条件、弱反对或强烈反对特定干预。LN 管理的其他方面（诊断、一般治疗原则、合并症和难治性病例的治疗）通过文献回顾和专家意见进行评估。
所有 SLE 患者均应进行肌酐和尿液检查以评估肾脏受累情况。肾活检被认为是诊断 LN 的金标准，但如果不可用或该程序存在禁忌症，则应根据临床和实验室参数做出治疗决策。制定了 14 项建议。目标肾反应（TRR）定义为治疗开始时肾功能改善或维持（治疗前±10%），同时 3 个月时 24 小时蛋白尿或 24 小时尿蛋白/肌酐比值下降 25%，6 个月时下降 50%，12 个月时蛋白尿<0.8g/24 小时。除禁忌症外，应向所有 SLE 患者开具羟氯喹。糖皮质激素应使用最低剂量和最短时间。在 III 级或 IV 级（±V 级），可使用霉酚酸酯（MMF）、环磷酰胺、MMF 加他克莫司（TAC）、MMF 加贝利单抗或 TAC 作为诱导治疗。对于维持治疗，MMF 或硫唑嘌呤（AZA）是首选，不能使用 MMF 或 AZA 的患者可使用 TAC、环孢素或来氟米特。在难治性疾病的情况下，可以开利妥昔单抗。在未能达到 TRR 的情况下，重要的是评估依从性、免疫抑制剂剂量、辅助治疗、合并症，并考虑活检/再活检。
本共识提供了循证数据，以指导 LN 的诊断和治疗，支持在巴西制定公共和补充卫生政策。
