Childhood-onset lupus nephritis: unique aspects and challenges in management

Childhood-onset lupus nephritis is an important glomerular disease that requires safe and effective treatments to reduce the incidence of chronic kidney disease and kidney failure. Novel treatments have become available for adults in the last decade, notably belimumab, obinutuzumab, and voclosporin. In contrast, most children with lupus nephritis are treated with conventional immunosuppression, and treatment recommendations are extrapolated from adult data because pediatric patients have historically been rarely included in clinical trials. However, children are not small adults with evolving immune systems, and there is a significant role of genetics contributing to the complex disease pathogenesis. In this mini review, we will highlight several unique aspects in managing childhood-onset lupus nephritis, including the optimal definition of disease remission, prevention of relapse, the delicate balance between treatment efficacy and side effects, and monogenic forms of lupus nephritis. We will also discuss how treatment adherence and dedicated transition care can affect treatment outcomes.