Thread by @Alexgr23

Such a great discussion on Refractory Lupus Nephritis on today’s @GlomCon Glomerular Disease Fellowship session 😍

💡This is a really interesting algorithm for Refractory LN proposed by Dr @BradRovin 👏🏻

✅ Here are some great #NephPearls

#NephTwitter #HouseOfComplement

@GlomCon @BradRovin @Nefrontera @LGlomcon @OrhanEfe_ @SaynaNorouzi @BetterCallSeeth ✅Voclosporin and Belimumab are considered as second induction regimen if there is no remission

💡 This is because best results regarding renal response are seen in patients who have already been exposed to immunosuppressive therapies❗️

#NephTwitter #NephPearls

@GlomCon @BradRovin @Nefrontera @LGlomcon @OrhanEfe_ @SaynaNorouzi @BetterCallSeeth ✅ How do we choose the right second induction regiment agent?

🔴 If patient has an impaired kidney function ➡️ Belimumab
🟡 If the patient has heavy proteinuria ➡️ Voclosporin

Combined use of Voclosporin and Belimumab?

#NephTwitter #NephPearls

@GlomCon @BradRovin @Nefrontera @LGlomcon @OrhanEfe_ @SaynaNorouzi @BetterCallSeeth ✅ When should responses be expected?

🔵25% fall in proteinuria at 8 weeks predicts a 50% fall after 6 months of therapy.

🟢50% fall in proteinuria after 6 months of therapy predicts good long-term kidney survival. This is reached by >50% of patients.

#NephTwitter #NephPearls

@GlomCon @BradRovin @Nefrontera @LGlomcon @OrhanEfe_ @SaynaNorouzi @BetterCallSeeth ✅ What is Refractory Lupus Nephritis?

No response or worsening of proteinuria and serum creatinine after:
🟡Two different induction regimens
🔴After treatment for 4-6 months
🟢Patients taking their prescribed 💊
🔵Therapeutic doses

Assessing 💊 adherence is key ❗️
#NephPearls

@GlomCon @BradRovin @Nefrontera @LGlomcon @OrhanEfe_ @SaynaNorouzi @BetterCallSeeth ✅Persistence is NOT Resistance!

Some patients have an improvement in kidney function and a fall in proteinuria (but ❌0.5 g/day)

A repeat biopsy 🔪 could be useful to consider histological remission 🔬

Disease activity vs CKD vs different glomerular disease❗️

#NephPearls

@GlomCon @BradRovin @Nefrontera @LGlomcon @OrhanEfe_ @SaynaNorouzi @BetterCallSeeth ✅ For resistant LN, some options that can be considered (distinct B cell targets)

🔵Rituximab
🟢Intensive B cell depletion (rituximab + cyclophosphamide + steroids)
🟡Bortezomib
🔴Daratumumab

None have been tested in RCTs ➡️ difficult to choose/recommend one over another