[Treatments of lupus nephropathies]

Treatment of lupus nephritis is based on nonspecific immunosuppression. The initial dose is established according to severity of glomerular lesions in the WHO classification. This update focuses on diffuse proliferative glomerulonephritis. The wide use of cytotoxic agents, in particular cyclophosphamide pulses, is based on a small number of randomized studies from a single institution. Extrapolation of the conclusions of these trials has raised problems, illustrated by the experience of the Nephrology and Rheumatology Units of Hôpital Bichat. Taking into account the changes in long-term prognosis of lupus nephritis, we reevaluate the role of cytotoxic agents compared to conventional corticosteroid treatment, the choice of immunosuppressive agent (cyclophosphamide, azathioprine, cyclosporine A, etc.), the mode of administration (initial phase/maintenance phase) and the optimal length of treatment. For the choice of initial and subsequent treatment, the importance of precise evaluation of the risk of progression is underlined. Such evaluation must take into account the now better identified factors of risk of progression to renal failure as well as the clinical, laboratory and histologic response to initial treatment.