Role of antimalarials in lupus nephritis: a narrative review

Lupus nephritis (LN) is a severe and common kidney complication of patients with systemic lupus erythematosus (SLE). The manifestations of LN include proteinuria, haematuria, arterial hypertension, and/or progressive decline in glomerular filtration. Kidney involvement in patients with SLE is associated with increased mortality, particularly in those who progress to kidney failure. Effective management of LN aims to preserve long-term renal function by reducing the renal inflammatory and autoimmune response, as well as to prevent flares, to manage comorbidities, and improve patient life expectancy and quality of life while minimising the toxicities associated with medications. Increasing evidence supports the efficacy of antimalarial drugs, particularly hydroxychloroquine (HCQ), in managing SLE and LN. HCQ is indicated in all patients with LN in the absence of contraindications, due to its ability to prevent progression to renal disease in patients with SLE, promote LN remission, prevent progression to end-stage kidney disease or chronic kidney disease, and improve survival. Additionally, HCQ is safe and well tolerated, although monitoring for ocular toxicities, skin hyperpigmentation and cardiotoxicity is recommended. Nevertheless, some uncertainties persist regarding the nature, quality, and quantity of the evidence on HCQ, its optimal use, long-term safety, and efficacy across different patient populations. Monitoring HCQ blood levels may further enhance treatment by managing adverse events, assessing patient adherence, predicting clinical outcomes, and enabling individualised drug dosing. Although the mechanisms by which HCQ reduces inflammation are complex and not fully understood, ongoing research continues to advance our knowledge. This narrative review explores the diverse roles of HCQ in the management of LN.