Translating the 2024 ACR lupus nephritis guidelines to pediatric practice

Lupus nephritis (LN) is more common and often more aggressive in children than in adults, yet most randomized trials informing current LN management have enrolled adults. The 2024 American College of Rheumatology (ACR) guideline is the first ACR guideline on lupus nephritis to explicitly state that its recommendations apply to both adults and children, although its evidence base remains largely adult-derived. This review uses the 2024 ACR guideline as an organizing framework, cross-referenced with the 2024 KDIGO and 2025 EULAR recommendations, to examine which aspects of LN management translate effectively to pediatric practice and which require caution. We review the diagnostic pathway, including screening, kidney biopsy, and ISN/RPS classification, as well as therapeutic strategies, including the shift from sequential dual therapy to upfront triple therapy, response targets, class-specific treatment, and selection between belimumab and calcineurin inhibitors. We then examine areas where pediatric evidence remains limited, particularly glucocorticoid dosing, long-term biologic safety, fertility and growth, and transition to adult care. While the fundamental principles of LN management are largely age-agnostic, many quantitative recommendations are not. Steroid dosing, long-term treatment exposure, and developmental consequences remain important pediatric-specific considerations that current guidelines cannot fully address. We conclude by highlighting the pediatric evidence available to date and the need for dedicated pediatric trials to replace adult-derived extrapolation with child-specific evidence.