Tailoring KDIGO guidelines for lupus nephritis to the real world: a stratified and cost-aware approach

Translating the 2024 KDIGO (Kidney Disease: Improving Global Outcomes) lupus nephritis (LN) guideline update into routine care remains challenging. While clinical trial data support early multi-agent combination therapy for nephritis to optimize kidney protection, real-world implementation is constrained by disease heterogeneity, disparities in access to advanced therapeutics, and limited incorporation of cost-effectiveness considerations. In this perspective article, we propose a pragmatic framework to adapt KDIGO recommendations to diverse healthcare settings. First, we propose a stratification model integrating clinical response kinetics, serological markers, and histological chronicity. Second, we apply implementation science frameworks to identify diagnostic and therapeutic gaps. Finally, we outline a value-based approach to evaluate the use of biologics and small molecules in terms of short- and long-term clinical outcomes and economic sustainability. Together, these strategies provide a roadmap to improve the real-world applicability of modern LN management.