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  The principal goal of therapy in lupus nephritis is to normalize renal function or, at least, to prevent the progressive loss of renal function. Therapy differs, depending on the pathologic lesion.
  Key points of American College of Rheumatology guidelines for managing lupus nephritis are as follows:
  Patients with clinical evidence of active, previously untreated lupus nephritis should have a renal biopsy to classify the disease according to ISN/RPS criteria
  All patients with lupus nephritis should receive background therapy with hydroxychloroquine, unless contraindicated
  Glucocorticoids plus either cyclophosphamide intravenously or mycophenolate mofetil orally should be administered to patients with class III/IV disease; patients with class I/II nephritis do not require immunosuppressive therapy
  Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers should be administered if proteinuria reaches or exceeds 0.5 g/day
  Blood pressure should be maintained at or below 130/80 mm Hg
  Patients with class V lupus nephritis are generally treated with prednisone for 1-3 months, followed by tapering for 1-2 years if a response occurs. If no response occurs, the drug is discontinued. Immunosuppressive drugs are generally not used unless renal function worsens or a proliferative component is present on renal biopsy samples.
  Investigational therapies for lupus nephritis and SLE include the following:
  Other anti-CD20 monoclonal antibodies (eg, ocrelizumab, ofatumumab, epratuzumab, and TRU-015)
  Anticytokine therapies (eg, monoclonal antibodies directed against interferon alfa, interleukin [IL]-1, IL-6, IL-10, and tumor necrosis factor alpha [TNF-α])
  Patients with end-stage renal disease require dialysis and are good candidates for kidney transplantation. Hemodialysis is preferred to peritoneal dialysis.


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