March is Kidney Month!
In November 2024, the American College of Rheumatology (ACR) released a summary of their new guidelines for the screening, treatment, and management of lupus nephritis.
What is important for a patient with lupus nephritis to know? We have answers to some commonly asked questions.
Why do professional organizations develop guidelines? [1,2]
Professional organizations like the ACR write clinical practice guidelines to help people get the right care for their disease. One goal of the guidelines is to reduce differences in how healthcare providers treat illnesses, especially across different geographic areas. The guidelines also help healthcare providers to wisely use resources, like screening tools and medications for lupus nephritis.
The overall goal of clinical practice guidelines is to improve care and achieve good results! For lupus nephritis, the new ACR guidelines aim to preserve kidney function, reduce poor outcomes, and decrease the number of medication-related side effects, although following professional guidelines doesn’t always promise a specific outcome.
How are new guidelines developed/adopted? [3,4]
Clinical practice guidelines aren’t developed overnight! In fact, the last time the ACR released clinical guidelines for lupus nephritis was in 2012. Experts at the ACR use a multi-step process to write clinical practice guidelines for lupus nephritis:
First, a project goal for the disease state is selected and a guidelines team is chosen. This team may include doctors, other healthcare professionals, epidemiology and biostatistics experts, and patients.
Next, the most important clinical questions about the disease (in this case, lupus nephritis) are identified. Feedback on the team’s project plan is then gathered from the public via the ACR website and a guidelines subcommittee.
This is followed by a detailed review of all existing research which is used to write recommendations. After the first draft of the guidelines is reviewed by experts at the ACR, a summary of the guidelines is prepared and undergoes even more examination through a process called journal peer review (where other rheumatology experts evaluate the findings before publication).
Once the guidelines are published and shared, the final step is to reevaluate any need for updates and revisions. Developing new clinical practice guidelines can take years!
What is contained in the new guidelines? [2,5]
The new guidelines provide expert advice for adults, adolescents, and children with lupus nephritis. A renewed focus has been placed on screening patients for lupus nephritis early, making a diagnosis quickly, and choosing the best ways to treat and manage this disease over the long term.
Screening
The new guidelines advise all patients with lupus to have their urine checked regularly (urinalysis) for abnormal amounts of protein (proteinuria), which may be a sign of kidney disease. This should be done every 6 to 12 months, and at any time a flare-up of lupus disease occurs. Once a patient has a kidney biopsy and is diagnosed with lupus nephritis, the guidelines then recommend more frequent checking of the urine, every 3 months. Finally, when the kidneys are working well again, urine checks can be stretched to once every 3 to 6 months.
Diagnosis
Lupus nephritis is diagnosed by performing a kidney biopsy. A kidney biopsy is performed by inserting a thin needle through the back and into the kidney to get a sample of tissue cells to look at underneath a microscope. The new guidelines state that a kidney biopsy should be done promptly whenever lupus nephritis is suspected.
Treatment
The guidelines have placed an increased emphasis on starting a class of medications called glucocorticoids—also known as “steroids”—right away, when lupus nephritis is suspected, even before a formal diagnosis is made.
All medicines can have side effects, and the new guidelines also recommend that steroids be used in lower doses (≤ 5 mg/day by the 6-month mark of treatment) to lessen the chance of toxicity, with a total duration of 3-5 years for those who do well with this treatment.
When lupus nephritis is severe, other medications are ideally added to steroids to form “triple therapy.” Triple therapy includes two other medicines that suppress the immune system (usually a medicine that contains mycophenolic acid, like mycophenolate mofetil, plus one other).
Management
Once treatment for lupus nephritis treatment begins, the guidelines state you should have your blood and urine tested at least every 3-6 months. The guidelines also emphasize the importance of health care providers and patients discussing and finalizing management decisions for lupus nephritis together, since many factors affect the choice of which screenings and medications to use. This is referred to in the guidelines as “shared decision-making.”
How are guidelines used by doctors and other healthcare providers? [1]
Guideline recommendations are not rules for treating any one specific patient. Rather, they are meant to offer advice to healthcare providers about different ways to treat patients with lupus nephritis. The guidelines are considered an optional tool that may be used based on each patient’s unique clinical situation.
How can patients use the new guidelines to advocate for themselves?
When you have a diagnosis of lupus, it’s important to be aware of the new clinical guidelines for lupus nephritis so that you can ask your healthcare provider about important screenings. If you’ve already been diagnosed with lupus nephritis, you’ll be better prepared to ask the right questions about your diagnosis and participate in management decisions.
It’s important to remember that you are not alone if you are diagnosed with lupus nephritis. Many different health care providers, like internal medicine doctors, rheumatologists, nephrologists, and their teams of nurse practitioners, physician assistants, nurses, and pharmacists can assist with shared decision-making and finding the right treatment plan for you.
Online sources, like the Lupus Nephritis Information Center from the Lupus Foundation of America, also have multiple resources to support you in your health care journey!
This post was originally published on this site