"A Change Is Gonna Come" to Treatment of Lupus Nephritis: A Review

Systemic lupus erythematosus (SLE) is a chronic, multiorgan autoimmune disease, with lupus nephritis (LN) affecting up to 60% of patients. Early diagnosis and treatment are critical for preserving kidney function. Advances in understanding the immunopathogenesis of LN are driving the development of personalized treatment strategies that hold promise for transforming disease management through interventions targeting distinct immunologic and histopathologic features. In this review, we discuss current and emerging therapies for proliferative and membranous LN with a focus on strategies targeting underlying mechanisms of disease in LN. Glucocorticoids with cytotoxic agents or mycophenolate mofetil (MMF) remain the standard of care, but newer therapies targeting B cells (eg, belimumab and obinutuzumab) and T cells (eg, voclosporin) have proven efficacy as add-on treatments. Novel therapies such as complement and cytokine inhibitors are being evaluated in preclinical and clinical trials. Although maintenance therapy with MMF remains the standard, the distinction between sequential induction and maintenance therapy has become increasingly blurred, and new strategies to reduce long-term disease and pharmacologic toxicity to improve remission and relapse rates are emerging.