Minimising steroids in lupus nephritis--will B cell depletion pave the way?

The aim of this review is to briefly explore how steroids came to be a presumed adjunct to all treatment regimens for lupus nephritis, despite being the main cause of long term damage among patients with lupus and despite increasingly effective alternative agents. I then go on to compare and contrast how differently immunosuppression regimens have developed in the world of solid organ transplantation. Almost from the start of transplantation a clear goal was to develop steroid sparing regimens - and now units such as our own routinely use induction with a biological, a single week of steroids and then monotherapy with tacrolimus. There has been a clear trend of using biologicals as induction agents and less immunosuppression in the long run but with improved outcomes. The drive has not been the same in lupus nephritis despite there being almost no evidence to support the use of steroids and certainly nothing to suggest correct dosage and timing. Rituximab, a B cell depleting antibody, offers great promise as a treatment agent despite the negative randomised control LUNAR trial. I briefly review our own data, demonstrating that early use of rituximab in lupus nephritis allows omission of oral steroids with excellent rates of remission (complete and partial). I review why the LUNAR trial should not discourage the use of rituximab. Finally, I introduce the RITUXILUP trial, a multicentre randomised controlled trial we are developing to formally evaluate our oral steroid avoiding regimen against a standard treatment regimen of mycophenolate mofetil and steroids. We have to follow the lead of our transplant colleagues and challenge the assumption that the future for lupus nephritis cannot be steroid free.