Эксперты KDOQI призывают к ранней диагностике и персонализированной терапии волчаночного нефрита

A Kidney Disease Outcomes Quality Initiative (KDOQI) work group recently commented on the 2024 KDIGO Clinical Practice Guideline for the Management of Lupus Nephritis (LN), by providing perspective for implementation in the US. Both organizations support earlier LN detection, combination immunosuppression, and corticosteroid minimization while emphasizing individualized treatment. The 2026 commentary highlights the expanding LN therapeutic landscape since 2024 that now includes obinutuzumab, belimumab, and voclosporin and emerging chimeric antigen receptor (CAR) T-cell approaches under trial, Sayna Norouzi, MD, at Loma Linda University Medical Center in California, and Gabriel N. Contreras, MD, MPH, at Miami Miller School of Medicine in Florida, noted on behalf of the KDOQI work group in their commentary published in the American Journal of Kidney Diseases. The KDOQI work group agrees with 2024 KDIGO recommendations to screen patients with systemic lupus erythematosus (SLE) for LN at disease onset, follow-up visits, and flares using serum creatinine and estimated glomerular filtration rate (eGFR), urinalysis, urinary protein-creatinine ratio (UPCR), complement levels, and anti-double-stranded DNA (anti-dsDNA). The KDOQI work group additionally favors a comprehensive antinuclear antibody panel because anti-dsDNA testing has only 66.7% to 79.5% sensitivity, with false-negative rates of 20.5% to 25.3%. Kidney biopsy should be considered with proteinuria higher than 500 mg/d or UPCR higher than 500 mg/g, abnormal urinary sediment, or worsening kidney function. The KDOQI work group further highlights that sterile pyuria may signal active LN and should not be mistaken for urinary tract infection. Other kidney pathologies also may exist alongside LN at biopsy. Current monitoring intensity generally reflects disease risk. Although the 2024 American College of Rheumatology guideline recommends testing every 6 months after relapse control and every 12 months in long-standing inactive disease, the KDOQI work group favors monthly testing during induction and quarterly testing during maintenance, particularly among high-risk patients. Classes 1 and 2 LN generally do not require disease-specific immunosuppression, but 34% to 63% of patients with class 2 disease may transform to classes 3, 4, and/or 5, supporting continued surveillance and repeat biopsy when kidney function deteriorates. For induction therapy in patients with active class 3 or 4 LN, the KDOQI work group supports KDIGO recommendations to use glucocorticoids combined with mycophenolic acid analogs (MPAA), low-dose intravenous cyclophosphamide, belimumab plus MPAA or cyclophosphamide, or an MPAA plus calcineurin inhibitor when kidney function is not severely impaired. The KDOQI work group noted that, in trials, complete renal remission was higher with triple therapy than double therapy adding tacrolimus (45.9% vs 25.6%; P <.001), voclosporin (41% vs 23%; P <.0001), belimumab (30% vs 20%; P =.02), and obinutuzumab (46.4% vs 33.1%; P =.02), without excessive serious adverse or infectious events. The KDOQI work group also endorses reduced-dose glucocorticoids after short methylprednisolone pulses when renal and extrarenal disease improve, with prednisone tapered to under 5 mg/d by weeks 21 to 24. Approximately 10% of patients with LN still develop end-stage kidney disease, making kidney replacement planning essential. KDOQI endorses preemptive kidney transplantation as the preferred option when feasible, although fewer than 5% of US patients with LN and end-stage kidney disease receive it. The KDOQI commentary further addressed treatment of special populations, such as children, women desiring pregnancy, and LN with thrombotic microangiopathy. “Although the [2024 KDIGO] guidelines offer general plans and recommendations, management of LN has moved toward more individualized treatment, especially in centers with dedicated glomerular disease clinics,” the KDOQI commentary authors pointed out. References: Norouzi S, Contreras GN. KDOQI US commentary on the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus Nephritis. Am J Kidney Dis. 2026;88(2):179-195. doi:10.1053/j.ajkd.2026.05.002