Recent advances in immunosuppressive therapy for lupus nephritis

Lupus nephritis (LN) is one of the most important manifestations in patients with systemic lupus erythematosus (SLE). Although LN is associated with increased morbidity, mortality and healthcare costs, the advent of new immunosuppressive drugs and biologics in recent years has led to significant improvements in treatment outcomes. In addition to conventional dual therapy, evidence for triple therapy has been established. Triple therapy, which combines mycophenolate mofetil (MMF) with belimumab (BEL) or calcineurin inhibitors (CNIs, including voclosporin), or intravenous cyclophosphamide with BEL, has been recommended, particularly for active nephritis with poor prognostic factors. Since rapid reductions in proteinuria have been observed with CNIs, triple therapy combining MMF and CNIs have been conditionally recommended for LN patients with preserved renal function and severe proteinuria. In contrast, because BEL reduced disease activity and severe flares in non-renal symptoms, triple therapy including BEL has been conditionally recommended in LN patients with significant extra-renal SLE disease. Furthermore, the latest treatment recommendations from the European League Against Rheumatism had added the combination therapy of MMF plus obinutuzumab as an initial treatment option. In this review, we discuss the latest guidelines and recommendations for LN.