Evandro Mendes Klumb1, Clovis Artur Almeida Silva2, Cristina Costa Duarte Lanna3, Emilia Inoue Sato4, Eduardo Ferreira Borba5, João Carlos Tavares Brenol6, Elisa Martins das Neves de Albuquerque7, Odirlei Andre Monticielo8, Lilian Tereza Lavras Costallat9, Luiz Carlos Latorre10, Maria de Fátima Lobato da Cunha Sauma11, Eloisa Silva Dutra de Oliveira Bonfá5, Francinne Machado Ribeiro7. 1. Disciplina de Reumatologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil. Electronic address: klumb@uol.com.br. 2. Departamento de Pediatria, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil. 3. Departamento do Aparelho Locomotor, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil. 4. Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil. 5. Disciplina de Reumatologia da Faculdade de Medicina, Universidade de São Paulo, SP, Brasil. 6. Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil. 7. Disciplina de Reumatologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil. 8. Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil. 9. Disciplina de Reumatologia, Faculdade de Medicina, Universidade Estadual de Campinas, Campinas, SP, Brasil. 10. Serviço de Reumatologia, Hospital de Heliópolis, São Paulo, SP, Brasil. 11. Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal do Pará, Belém, PA, Brasil.
Abstract
OBJECTIVE: To develop recommendations for the diagnosis, management and treatment of lupus nephritis in Brazil. METHOD: Extensive literature review with a selection of papers based on the strength of scientific evidence and opinion of the Commission on Systemic Lupus Erythematosus members, Brazilian Society of Rheumatology. RESULTS AND CONCLUSIONS: 1) Renal biopsy should be performed whenever possible and if this procedure is indicated; and, when the procedure is not possible, the treatment should be guided with the inference of histologic class. 2) Ideally, measures and precautions should be implemented before starting treatment, with emphasis on attention to the risk of infection. 3) Risks and benefits of treatment should be shared with the patient and his/her family. 4) The use of hydroxychloroquine (preferably) or chloroquine diphosphate is recommended for all patients (unless contraindicated) during induction and maintenance phases. 5) The evaluation of the effectiveness of treatment should be made with objective criteria of response (complete remission/partial remission/refractoriness). 6) ACE inhibitors and/or ARBs are recommended as antiproteinuric agents for all patients (unless contraindicated). 7) The identification of clinical and/or laboratory signs suggestive of proliferative or membranous glomerulonephritis should indicate an immediate implementation of specific therapy, including steroids and an immunosuppressive agent, even though histological confirmation is not possible. 8) Immunosuppressives must be used during at least 36 months, but these medications can be kept for longer periods. Its discontinuation should only be done when the patient achieve and maintain a sustained and complete remission. 9) Lupus nephritis should be considered as refractory when a full or partial remission is not achieved after 12 months of an appropriate treatment, when a new renal biopsy should be considered to assist in identifying the cause of refractoriness and in the therapeutic decision.
OBJECTIVE: To develop recommendations for the diagnosis, management and treatment of lupus nephritis in Brazil. METHOD: Extensive literature review with a selection of papers based on the strength of scientific evidence and opinion of the Commission on Systemic Lupus Erythematosus members, Brazilian Society of Rheumatology. RESULTS AND CONCLUSIONS: 1) Renal biopsy should be performed whenever possible and if this procedure is indicated; and, when the procedure is not possible, the treatment should be guided with the inference of histologic class. 2) Ideally, measures and precautions should be implemented before starting treatment, with emphasis on attention to the risk of infection. 3) Risks and benefits of treatment should be shared with the patient and his/her family. 4) The use of hydroxychloroquine (preferably) or chloroquine diphosphate is recommended for all patients (unless contraindicated) during induction and maintenance phases. 5) The evaluation of the effectiveness of treatment should be made with objective criteria of response (complete remission/partial remission/refractoriness). 6) ACE inhibitors and/or ARBs are recommended as antiproteinuric agents for all patients (unless contraindicated). 7) The identification of clinical and/or laboratory signs suggestive of proliferative or membranous glomerulonephritis should indicate an immediate implementation of specific therapy, including steroids and an immunosuppressive agent, even though histological confirmation is not possible. 8) Immunosuppressives must be used during at least 36 months, but these medications can be kept for longer periods. Its discontinuation should only be done when the patient achieve and maintain a sustained and complete remission. 9) Lupus nephritis should be considered as refractory when a full or partial remission is not achieved after 12 months of an appropriate treatment, when a new renal biopsy should be considered to assist in identifying the cause of refractoriness and in the therapeutic decision.
Authors: Juliana C O A Ferreira; Vitor C Trindade; Graciela Espada; Zoilo Morel; Eloisa Bonfá; Claudia S Magalhães; Clovis Artur Silva Journal: Clin Rheumatol Date: 2018-08-09 Impact factor: 2.980
Authors: Michelle R Ugolini-Lopes; Luciana Parente C Seguro; Maitê Xavier F Castro; Danielle Daffre; Alex C Lopes; Eduardo F Borba; Eloisa Bonfá Journal: Lupus Sci Med Date: 2017-06-12
Authors: Guilherme Ramires de Jesus; Claudia Mendoza-Pinto; Nilson Ramires de Jesus; Flávia Cunha Dos Santos; Evandro Mendes Klumb; Mario García Carrasco; Roger Abramino Levy Journal: Autoimmune Dis Date: 2015-07-12
Authors: Marise Oliveira-Santos; José Fernando de Souza Verani; Luiz Antônio Bastos Camacho; Carlos Augusto Ferreira de Andrade; Rosele Ferrante-Silva; Evandro Mendes Klumb Journal: Trials Date: 2016-04-02 Impact factor: 2.279
Authors: Bernardo A Pons-Estel; Eloisa Bonfa; Enrique R Soriano; Mario H Cardiel; Ariel Izcovich; Federico Popoff; Juan M Criniti; Gloria Vásquez; Loreto Massardo; Margarita Duarte; Leonor A Barile-Fabris; Mercedes A García; Mary-Carmen Amigo; Graciela Espada; Luis J Catoggio; Emilia Inoue Sato; Roger A Levy; Eduardo M Acevedo Vásquez; Rosa Chacón-Díaz; Claudio M Galarza-Maldonado; Antonio J Iglesias Gamarra; José Fernando Molina; Oscar Neira; Clóvis A Silva; Andrea Vargas Peña; José A Gómez-Puerta; Marina Scolnik; Guillermo J Pons-Estel; Michelle R Ugolini-Lopes; Verónica Savio; Cristina Drenkard; Alejandro J Alvarellos; Manuel F Ugarte-Gil; Alejandra Babini; André Cavalcanti; Fernanda Athayde Cardoso Linhares; Maria Jezabel Haye Salinas; Yurilis J Fuentes-Silva; Ana Carolina Montandon de Oliveira E Silva; Ruth M Eraso Garnica; Sebastián Herrera Uribe; Diana Gómez-Martín; Ricardo Robaina Sevrini; Rosana M Quintana; Sergio Gordon; Hilda Fragoso-Loyo; Violeta Rosario; Verónica Saurit; Simone Appenzeller; Edgard Torres Dos Reis Neto; Jorge Cieza; Luis A González Naranjo; Yelitza C González Bello; María Victoria Collado; Judith Sarano; Soledad Retamozo; María E Sattler; Rocio V Gamboa-Cárdenas; Ernesto Cairoli; Silvana M Conti; Luis M Amezcua-Guerra; Luis H Silveira; Eduardo F Borba; Mariana A Pera; Paula B Alba Moreyra; Valeria Arturi; Guillermo A Berbotto; Cristian Gerling; Carla A Gobbi; Viviana L Gervasoni; Hugo R Scherbarth; João C Tavares Brenol; Fernando Cavalcanti; Lilian T Lavras Costallat; Nilzio A Da Silva; Odirlei A Monticielo; Luciana Parente Costa Seguro; Ricardo M Xavier; Carolina Llanos; Rubén A Montúfar Guardado; Ignacio Garcia de la Torre; Carlos Pineda; Margarita Portela Hernández; Alvaro Danza; Marlene Guibert-Toledano; Gil Llerena Reyes; Maria Isabel Acosta Colman; Alicia M Aquino; Claudia S Mora-Trujillo; Roberto Muñoz-Louis; Ignacio García Valladares; María Celeste Orozco; Paula I Burgos; Graciela V Betancur; Graciela S Alarcón Journal: Ann Rheum Dis Date: 2018-07-25 Impact factor: 19.103