Differences in management approaches for lupus nephritis within the UK

Sara T Ibrahim; Christopher J Edwards; Michael R Ehrenstein; Bridget Griffiths; Caroline Gordon; Peter Hewins; David Jayne; Liz Lightstone; Zoe McLaren; Benjamin Rhodes; Edward M Vital; John A Reynolds

doi:10.1093/rap/rkae017

Differences in management approaches for lupus nephritis within the UK

Rheumatol Adv Pract. 2024 Feb 9;8(1):rkae017. doi: 10.1093/rap/rkae017. eCollection 2024.

Authors

Sara T Ibrahim^{1

2}, Christopher J Edwards³, Michael R Ehrenstein⁴, Bridget Griffiths⁵, Caroline Gordon^{1

6}, Peter Hewins⁷, David Jayne⁸, Liz Lightstone⁹, Zoe McLaren¹⁰, Benjamin Rhodes¹¹, Edward M Vital^{12

13}, John A Reynolds^{1

6}

Affiliations

¹ Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.
² Internal Medicine and Nephrology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
³ NIHR Southampton Clinical Research Facility, University Hospital Southampton, Southampton, UK.
⁴ Department of Rheumatology, University College London, London, UK.
⁵ Department of Rheumatology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
⁶ Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK.
⁷ Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
⁸ Department of Medicine, University of Cambridge, Cambridge, UK.
⁹ Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK.
¹⁰ Department of Rheumatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
¹¹ Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
¹² Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
¹³ NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.

Abstract

Objectives: Outcomes of therapy for LN are often suboptimal. Guidelines offer varied options for treatment of LN and treatment strategies may differ between clinicians and regions. We aimed to assess variations in the usual practice of UK physicians who treat LN.

Methods: We conducted an online survey of simulated LN cases for UK rheumatologists and nephrologists to identify treatment preferences for class IV and class V LN.

Results: Of 77 respondents, 48 (62.3%) were rheumatologists and 29 (37.7%) were nephrologists. A total of 37 (48.0%) reported having a joint clinic between nephrologists and rheumatologists, 54 (70.0%) reported having a multidisciplinary team meeting for LN and 26 (33.7%) reported having a specialized lupus nurse. Of the respondents, 58 (75%) reported arranging a renal biopsy before starting the treatment. A total of 20 (69%) of the nephrologists, but only 13 (27%) rheumatologists, reported having a formal departmental protocol for treating patients with LN (P < 0.001). The first-choice treatment of class IV LN in pre-menopausal patients was MMF [41 (53.2%)], followed by CYC [15 (19.6%)], rituximab [RTX; 12 (12.5%)] or a combination of immunosuppressive drugs [9 (11.7%)] with differences between nephrologists' and rheumatologists' choices (P = 0.026). For class V LN, MMF was the preferred initial treatment, irrespective of whether proteinuria was in the nephrotic range or not. RTX was the preferred second-line therapy for non-responders.

Conclusion: There was variation in the use of protocols, specialist clinic service provision, biopsies and primary and secondary treatment choices for LN reported by nephrologists and rheumatologists in the UK.

Keywords: UK; lupus nephritis; refractory; treatment.