Management of newly diagnosed lupus nephritis in China: An implementation study based on the 2023 EULAR recommendations.

BACKGROUND

Current evidence demonstrates that rigorous adherence to the standardized diagnostic and therapeutic protocols outlined in the European League Against Rheumatism (EULAR) guidelines can markedly enhance renal survival rates in patients with lupus nephritis (LN) and lead to improved overall outcomes. Data on the real-world implementation of LN management guideline in China was limited. This study aimed to examine the implementation of the 2023 EULAR recommendations for systemic lupus erymatosus (SLE) and LN in China.

METHODS

Based on the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR) cohort, patients with newly diagnosed active LN (24-h Urine Protein ≥ 0.5 g/L) from April 2009 to March 2022 were included. The initial immunosuppressant therapy, the adjustment of immunosuppressant, and the implementation of renal biopsy at baseline were assessed. The patients' general conditions, clinical manifestations, the condition of rheumatologists and hospitals were included in the analysis.

RESULTS

Of the 1518 enrolled patients, 787 (52%) underwent cyclophosphamide or mycophenolate mofetil as the initial immunosuppressant, which was consistent with the EULAR recommendations. It was associated with longer disease duration, higher disease activity, more mucocutaneous involvement, and younger age of onset. Thirty out of 166 patients (18.1%) failed to achieve renal remission after 6 or 12 months of treatment, and 9 of whom had immunosuppressive therapy adjusted as recommended. Overall, 251 patients (16.5%) underwent renal biopsy at baseline, which were associated with significant renal involvement, unremarkable systemic involvement, and treated by senior rheumatologists.

CONCLUSIONS

Management of LN in China showed poor alignment with the 2023 EULAR recommendations regarding initial and adjusted therapy, as well as renal biopsy. The improvement of LN management requires both the patients and the rheumatologists to work together. Key Points • To the best of our knowledge, this is the first real-world implementation study of LN in China. This is also the first real-world implementation study for the newly updated EULAR 2023 recommendation for SLE. • We not only examined the consistency between LN management in China and EULAR recommendations, but also identified potential factors associated with the implementation of the recommendations. • We believe that our study makes a significant contribution to the management of LN.