• Lupus nephritis treatment aims to prevent further kidney damage.
• There are many kinds of medications used for lupus nephritis, including immunosuppressants, blood pressure medications, and diuretics.
• People with advanced stage lupus nephritis may need to rely on dialysis or a kidney transplant to restore their kidney function.
• Living a healthy lifestyle and eating a balanced diet can support kidney health.

Treatment for lupus nephritis focuses on preventing the progression of the condition and improving the symptoms associated with the disease. Lupus nephritis is a common condition that affects the kidneys of up to 50 percent of people living with systemic lupus erythematosus (SLE), or lupus. Lupus is an autoimmune disease that involves the immune system attacking many organs and tissues in the body. A person living with lupus develops lupus nephritis when the kidneys become damaged by the immune system and begin to decline in function.

Treatment Goals for Lupus Nephritis

Goals for the treatment of nephritis include preventing further damage to the kidneys and treating the symptoms associated with the decline in kidney function. The main objective is to slow or stop the progression of the disease and the eventual need for dialysis or a kidney transplant. Lupus nephritis treatment usually involves suppressing the immune system to limit damage to the kidney. Many of the therapies used for this are also used to treat lupus in general.

Important kidney functions affected by lupus nephritis include filtering waste and excess fluid out of the blood and into the urine, and regulating blood pressure. Lupus nephritis symptoms that require treatment include:

• Swelling (edema) in the legs, hands, and face
• High blood pressure
• Accumulation of waste in the blood

Treatment approaches will vary for people with lupus nephritis depending on the stage of the disease. There are six stages of lupus nephritis that progress in severity based on the amount of kidney damage and how well the kidneys are functioning. A doctor will run tests on the blood and urine, and may collect a kidney biopsy to determine the stage of lupus nephritis. People diagnosed with the later stages of lupus nephritis will require more intensive therapy.

Medications for Lupus Nephritis

There are several medications used to treat lupus nephritis. These medications are used to meet the treatment goals of preventing further kidney damage and managing the symptoms of declining kidney function.

Immunosuppressants

Immunosuppressants are used to suppress inflammation and overactivity of the immune system. During lupus nephritis, inflammation caused by the immune system can damage the kidneys. Immune cells can also attack the kidneys. There are several classes of immunosuppressant medications used to treat lupus nephritis.

Corticosteroids

Corticosteroids, sometimes referred to as glucocorticoids or simply as steroids, are artificial versions of the hormone cortisol that is naturally produced by the body. Steroids work by reducing the production of molecules that cause inflammation and suppressing the activity of cells in the immune system. Some common examples of steroids include prednisone, cortisone, and methylprednisolone. These drugs can be taken orally or through injection to treat lupus nephritis.

Although steroids are effective for reducing inflammation and the activity of the immune system, there are some serious side effects associated with their long-term use. These include high blood pressure, high blood sugar, and weakening of the bones (osteoporosis). A doctor may want to limit the amount of time a person uses steroids.

Chemotherapy Drugs

Some chemotherapy drugs can be used as immunosuppressants to treat lupus nephritis. Chemotherapy drugs prevent the growth and division of cells, including the cells in the immune system which replicate, or divide, when they are activated. This activation and cell division occurs during autoimmune disease and can lead to an attack on the body’s tissues — including the kidneys. Some common examples of chemotherapy drugs used to treat lupus nephritis include Cytoxan (cyclophosphamide) and mycophenolate mofetil.

Each type of chemotherapy drug used to treat lupus nephritis will have its own side effects. Common side effects include nausea, upset stomach, and fatigue.

Calcineurin Inhibitors

Calcineurin inhibitors work by inhibiting calcineurin, an enzyme inside immune cells. Inhibiting calcineurin can prevent immune cells from attacking the body’s own tissues. Common calcineurin inhibitors used for the treatment of lupus nephritis include Gengraf (cyclosporine) and Protopic (tacrolimus). The Food and Drug Administration (FDA) approved Lupkynis (voclosporin) to treat lupus nephritis in January 2021.

Calcineurin inhibitors must be carefully used during the treatment of lupus nephritis, as they can be harmful to the kidneys and liver. High blood pressure is another side effect associated with these medications.

Therapy With Biologics

Biologic treatments are designed to bind to various inflammatory molecules and cell types associated with lupus nephritis. They are given by injection, which allows the biologic to destroy or block its target in the body. Common side effects of biologic therapies include injection site reaction, joint pain, muscle soreness, sore throat, fatigue, headaches, and in rare cases, severe allergic reaction. The FDA approved Benlysta (belimumab) to treat lupus nephritis in December 2020.

Risk of Infection on Immunosuppressants

Immunosuppressants affect the immune system’s ability to fight off infection. As a result, a person using immunosuppressants to treat lupus nephritis should take precautions to avoid people who are sick or have an active infection. This includes practicing social distancing and minimizing exposure to the coronavirus during the COVID-19 pandemic.

Blood Pressure Medications

The kidneys are involved in regulating blood pressure. Damage to the kidney and medications like oral steroids can cause high blood pressure for people with lupus nephritis. Unfortunately, high blood pressure can further damage the kidneys, making it important to control high blood pressure during the treatment of lupus nephritis. Controlling blood pressure can also prevent proteinuria, which occurs when excess protein leaks into the blood causing foamy urine.

Common blood pressure medications used to treat lupus nephritis symptoms include ACE inhibitors and ARBs.

Diuretics

The kidneys remove excess fluid from the body. The kidney damage that occurs during lupus nephritis can affect this function. Diuretics are medications used to remove fluid from the body. They can also help reduce blood pressure. Commonly used diuretics for the treatment of lupus nephritis include Lasix (furosemide) and HCTZ (hydrochlorothiazide).

Treatments for Advanced Stage Lupus Nephritis

People diagnosed with stage 6 lupus nephritis usually require more intensive therapy. Stage 6 lupus nephritis is diagnosed when 90 percent or more of the kidney has been damaged, and kidney function is very poor. Treatment for stage 6 lupus nephritis must replace the function of the kidneys. Options include dialysis and kidney transplantation.

Dialysis

Dialysis is a medical procedure that removes waste and certain chemicals from the blood. Healthy kidneys are able to do this for the body, but once a person loses kidney function, they must rely on dialysis to clean the blood. There are two types of dialysis: hemodialysis and peritoneal dialysis. In hemodialysis, the blood is extracted and cleaned with a dialysis machine. In peritoneal dialysis, waste is drawn out of the body by putting dialysis fluid in the abdomen.

Both types of dialysis clean the blood by removing waste, salt, and excess water from the body. Dialysis also ensures the levels of potassium, bicarbonate, and sodium in the blood are balanced. This procedure can also help control blood pressure.

Dialysis must be performed often, and it can be time consuming. For example, hemodialysis can take up to four hours and is typically performed three times per week.

Kidney Transplant

An alternative to dialysis is receiving a kidney transplant. A kidney transplant can restore kidney function. Getting a transplant involves working with a transplant center, undergoing a medical evaluation to determine if a transplant is the right approach, finding a donor who is the right match, and then having the transplant operation. Finding a donor may be a challenge because the two individuals must have certain matching characteristics to make sure the body does not reject the transplant. Following the transplant operation, the recipient will have to take antirejection medications to prevent the body from attacking the transplanted kidney.

The recurrence of lupus nephritis in the new kidney is possible, and some people living with lupus nephritis may end up needing kidney transplantation again.

Lifestyle Habits To Support Kidney Health

Living a healthy lifestyle can support kidney health and help manage lupus nephritis. Habits that support overall and kidney health include:

• Regular exercise
• A low sodium (less than 2,300 milligrams per day) diet
• A low cholesterol diet
• Adequate hydration
• Limited alcoholic drinks
• No smoking

Connect With Others Who Understand

MyLupusTeam is the social network for people with lupus and their loved ones. On MyLupusTeam, more than 187,000 members come together to ask questions, give advice, and share their stories with others who understand life with lupus and lupus nephritis.

Are you living with lupus nephritis? Which treatments have worked for you? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References

1. Biomarkers in systemic lupus erythematosus: challenges and prospects for the future — Therapeutic Advances in Musculoskeletal Disease
2. The Pathogenesis of Lupus Nephritis — Journal of the American Society of Nephrology
3. How Your Kidneys Work — National Kidney Foundation
4. Diagnosing Lupus Nephritis — Yale Medicine
5. Corticosteroids — Cleveland Clinic
6. Updates on the Treatment of Lupus Nephritis — Journal of American Society for Nephrology
7. Calcineurin Inhibitors — StatPearls
8. Pharmacologic Immunosuppression — Frontiers in Bioscience
9. What are Biologics? — U.S. Food and Drug Administration
10. Role of the Kidneys in the Regulation of Intra-and Extra-Renal Blood Pressure — Annals of Clinical Hypertension
11. How Does Lupus Affect the Cardiovascular System — Johns Hopkins Lupus Center
12. Lupus Nephritis — Mayo Clinic
13. Dialysis — National Kidney Foundation