SLE Patient - Kidney Evaluation
Patient with SLE requiring renal screening or known LN
All Pathways
RheumatologyManagement
Lupus Nephritis Management (ACR 2024)
Lupus Nephritis Management (ACR 2024): SLE Patient - Kidney Evaluation → Screening for Lupus Nephritis → Proteinuria >0.5 g/g or Impaired eGFR? → Kidney...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Screening for Lupus Nephritis
Strong recommendation
- Screen q6-12 months if no known kidney disease
- Screen at extrarenal flares
- Urine protein/creatinine ratio (UPCR)
- Urinalysis with microscopy
- Serum creatinine and eGFR
03Decision Proteinuria >0.5 g/g or Impaired eGFR?
Unexplained by other causes
04Action Kidney Biopsy
Conditional recommendation
- Biopsy if UPCR >0.5 g/g and/or unexplained impaired eGFR
- Classify per ISN/RPS 2003 (or 2018 revision)
- Assess activity index and chronicity index
- Identify concurrent pathology (TMA, APS nephropathy)
05Decision LN Class?
Based on kidney biopsy findings
- Class I/II: Minimal/mesangial - mild disease
- Class III: Focal proliferative (<50% glomeruli)
- Class IV: Diffuse proliferative (≥50% glomeruli)
- Class V: Membranous (can be pure or combined)
- Class VI: Sclerotic (>90% sclerosis) - limited treatment options
06Action Class I/II LN
Minimal/mesangial disease
- Usually no immunosuppression needed for LN itself
- Treat extrarenal SLE as indicated
- HCQ continuation mandatory
- ACEi/ARB if proteinuria or hypertension
- Monitor for progression
07Outcome LN Controlled
Complete response, stable renal function, maintenance therapy
08Action Class III/IV LN (Proliferative)
Triple immunosuppressive therapy
- Glucocorticoid + TWO additional IS agents (Conditional):
- Option 1: MMF + Belimumab
- Option 2: MMF + Calcineurin inhibitor (voclosporin or tacrolimus)
- Option 3: Cyclophosphamide-based (Euro-Lupus or NIH regimen)
- HCQ continuation mandatory
09Action Glucocorticoid Protocol
Lower-dose regimen (Conditional)
- IV pulse methylprednisolone 250-1000mg x1-3 days
- Then oral prednisone 0.5 mg/kg/day (MAX 40 mg/day)
- TAPER to ≤5 mg/day by 6 months
- Goal: lowest effective dose or discontinuation
- Add IS early to enable GC reduction
10Warning ⚠️ Voclosporin Considerations
FDA-approved for LN
- 23.7 mg BID (fixed dose, not weight-based)
- Avoid if eGFR <45 mL/min/1.73m²
- Monitor for nephrotoxicity
- Drug interactions: avoid strong CYP3A4 inhibitors
- Hypertension management
11Decision Response Assessment
Monitor proteinuria, creatinine, urinalysis
- Complete response: UPCR <0.5 g/g + stable eGFR
- Partial response: ≥50% reduction in proteinuria
- If not in complete response: check q3 months (Strong)
- If sustained complete response: check q3-6 months
12Action Maintenance Therapy
3-5 years for complete responders
- Continue MMF (or azathioprine if MMF intolerant)
- Continue HCQ (lifelong in SLE)
- May continue belimumab or voclosporin if used in induction
- Minimize/discontinue glucocorticoids
- Regular monitoring for flares and drug toxicity
- Path rejoins step 07Shared downstream outcome
13Action Refractory LN
Failure to respond or relapse
- Consider repeat biopsy to assess activity vs chronicity
- Switch induction regimen (e.g., CYC to MMF or vice versa)
- Add rituximab (off-label but evidence-supported)
- Intensify CNI if not used
- Clinical trial or transplant evaluation if ESRD
14Warning Nephrology Co-Management
Refractory disease, declining eGFR, ESRD planning
15Action Pure Class V LN (Membranous)
If proteinuria >1 g/g
- Glucocorticoid + MMF + Calcineurin inhibitor (Conditional)
- Voclosporin preferred CNI (FDA approved)
- Alternative: MMF alone or with rituximab
- HCQ continuation mandatory
- ACEi/ARB for proteinuria reduction
- Path rejoins step 09Shared downstream outcome
16Action Supportive Measures
For all LN patients
- ACEi or ARB for proteinuria/hypertension
- BP target <130/80 mmHg
- Lipid management (statins if indicated)
- Vitamin D supplementation
- Infection prophylaxis during intense IS
- Bone protection if prolonged GC use
- Path rejoins step 07Shared downstream outcome
Guideline Source
2024 ACR Guideline for the Screening, Treatment, and Management of Lupus Nephritis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Pediatric LN may require specialized dosing
- Transplant-related LN not covered
- ESRD management not addressed
- Rapidly progressive GN may need emergent nephrology
- Concurrent APS nephropathy requires additional management
Applicable Regions
USEUAU
AU: ARA/ANZSN endorses ACR recommendations
EU: EULAR/ERA-EDTA 2020 also available
US: ACR 2024 is primary guidance
Version 1Next review: 2028-01-01
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Lupus Nephritis Management (ACR 2024)?
The Lupus Nephritis Management (ACR 2024) is a management clinical algorithm for Rheumatology. It provides a structured decision tree to guide clinical decision-making, based on 2024 ACR Guideline for the Screening, Treatment, and Management of Lupus Nephritis.
What guideline is the Lupus Nephritis Management (ACR 2024) based on?
This algorithm is based on 2024 ACR Guideline for the Screening, Treatment, and Management of Lupus Nephritis (DOI: 10.1002/art.43212).
What are the limitations of the Lupus Nephritis Management (ACR 2024)?
Known limitations include: Pediatric LN may require specialized dosing; Transplant-related LN not covered; ESRD management not addressed; Rapidly progressive GN may need emergent nephrology; Concurrent APS nephropathy requires additional management. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Lupus Nephritis Management (ACR 2024) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free