Dr Konstantinos Tselios presented work on the impact of time to remission and flares on the development of advanced CKD in LN. Using data from the Toronto Lupus Clinic database, the group showed that 15.8% developed advanced CKD after 9.5 years. At baseline, these patients had a higher SLICC/Damage Index, lower estimated glomerular filtration rate, higher prevalence of hypertension, proliferative nephritis, and were more often treated with ACE inhibitors or angiotensin receptor blockers.
Importantly, complete remission within the first year from LN diagnosis strongly protected against advanced CKD. However, experiencing just one flare was associated with 2.7-fold increased risk for advanced CKD. Longer time on immunosuppressives after remission was associated with decreased risk for advanced CKD. These findings emphasize the importance of early remission as well as flare prevention with prolonged immunosuppressive to maximize renal survival in LN.
Severe (proliferative) forms of LN are treated with induction immunosuppressive therapy (IST), followed by maintenance IST. The optimal duration of maintenance IST for proliferative LN is unknown. Professor Dr Noemie Jourde-Chiche shared results of the WIN-Lupus trial, which tested whether maintenance IST discontinuation after 2–3 years in patients in remission after a proliferative LN is non-inferior to IST continuation for 2 more years.
In the per-protocol population, a relapse occurred in 10.4% with IST continuation, and 25% with IST discontinuation. Non-inferiority was not demonstrated for relapse rate. Time to renal relapse did not differ between groups, and severe SLE flares (renal or extra-renal) were less frequent in patients with IST continuation compared to discontinuation, but adverse events did not differ between groups.
An abstract on integrated multilevel omics analysis revealed a set of enriched pathways of potential interest for future drug investigation in LN, with implications for proteasome inhibition. Dr Ioannis Parodis and colleagues analysed differentially expressed genes (DEGs), pathways and their druggability via the Drug Gene Interaction database (DGIdb) in 41 patients with active LN versus healthy controls. In total, 6,869 significant and validated DEGs were identified in active LN. These genes could be targeted by 203 different drugs, with the proteasome inhibitor bortezomib interfering with cathepsin B (CTSB) regulation and cyclophosphamide interfering with the regulation of tumour necrosis factor receptor superfamily member 1A (TNFRSF1A) being of particular interest.
In 2020 EULAR – the European Alliance of Associations for Rheumatology – and the European Renal Association (ERA) published updated treatment recommendations for LN. The outline targeted reductions in proteinuria over the course of the first year of therapeutic intervention. Dr Hans-Joachim Anders reported on a post-hoc analysis of pooled voclosporin data from the AURA-LV and AURORA-1 studies based on these updated response criteria.
The novel calcineurin inhibitor voclosporin was approved in 2021 in the USA for the treatment of adult patients with active LN in combination with background immunotherapy. Within the first 3 months of treatment, 78.4% of patients on voclosporin and 62.4% in the control group achieved ≥25% reduction in urine protein creatinine ratio (UPCR). After 12 months, 52.6% and 33.1% of those receiving voclosporin and control, respectively, had achieved UPCR ≤0.7 mg/mg.
The results suggest that addition of voclosporin to a background regimen of mycophenolate mofetil and low-dose steroids in patients with LN significantly increased the likelihood of achieving the UPCR targets of therapy recommended by EULAR/ERA.