New Guidelines Issued for Severe Lupus
More can be done to prevent permanent kidney damage, says American College of Rheumatology
Thursday, May 3, 2012
Because kidney inflammation (also called lupus nephritis) is so common in people with lupus, the American College of Rheumatology has issued new guidelines for the screening and management of this potentially devastating complication of lupus.
"Without treatment, lupus nephritis can lead to end-stage-renal disease, which requires dialysis or a kidney transplant. But, not all types are this serious. It depends on the pattern of damage to the kidneys," said the lead author of the new guidelines, Dr. Bevra Hahn, a professor of medicine and chief of rheumatology at the David Geffen School of Medicine at the University of California, Los Angeles.
Hahn said the course of lupus nephritis can vary greatly from patient to patient. And, that means that treatment decisions need to be individualized.
The guidelines, released online May 3, will be published in the June issue of Arthritis Care & Research.
Lupus -- short for systemic lupus erythematosus (SLE) -- is a chronic autoimmune disease. That means that the body's immune system mistakenly attacks healthy cells in the body. The most commonly affected areas are the joints and skin, but lupus can affect any body part, including the kidneys. The disease is mild in some people and more severe in others. There are also symptom-free periods of time, and then the disease flares again.
If the kidneys are involved, quality of life and survival rates suffer. Normally, the survival rate is 92 percent after 10 years with lupus. If the kidneys are involved, survival drops to 88 percent, according to the guidelines. Blacks have an even lower survival rate when the kidneys are affected.
Fortunately, treatments exist for people with lupus nephritis.
If you haven't received treatment for lupus nephritis, and you show signs of kidney involvement, the first step is generally to get a kidney biopsy, according to the guidelines. This is so your doctor knows exactly what type of lupus nephritis you have, how aggressive it is, and how much of the kidney is damaged. This information helps to guide treatment decisions, Hahn said.
She said everyone with lupus nephritis should be given the drug hydroxycholoquine, and if there's any sign of protein in the urine, they should also be on blood pressure-lowering medications called ACE inhibitors or angiotensin-receptor blockers (ARBs). These have a protective effect on the kidneys, independent of their ability to lower blood pressure. If cholesterol is high, it's important to get the "bad" (LDL) cholesterol under control, said Hahn.
For more serious disease, drugs that suppress the immune system and reduce inflammation are recommended. These include glucocorticoids, azathioprine and mycophenolate mofetil.
Despite new treatments, however, the rate of end-stage renal disease has increased since 1982. Hahn said it isn't clear why that's happened, and she hoped more recent data will show an improvement with use of some newer treatments.
Dr. Richard Furie, chief of the division of rheumatology at the North Shore-LIJ Health System in Lake Success, N.Y., welcomed the recommendations.
"These new guidelines will add some uniformity to the way we approach lupus nephritis," he said.
Furie added that while newer treatments have helped treat people with lupus, "they don't do such a great job with lupus nephritis. A really good response only occurs in about 25 to 50 percent of patients."
Both experts said that people with lupus should follow the advice for heart-healthy living. That means don't smoke, eat right and try to get some exercise.
Hahn said to aim for at least 15 minutes of walking three to four times a week. "Try to keep yourself in good aerobic shape. And, if you can do more, that's better." But, she said, it's also important to rest when you need to.
As for diet, Hahn said previous research has shown that a diet heavy in trans fats or meat fats promotes inflammation, so it may help to avoid those types of foods.
The most important thing, Hahn said, is to stick with your medication regimen. And, if you can't take your medication because of side effects or cost, it's important to discuss that with your doctor.
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