(Level 2b) MMF dose during induction therapy should be 1 5–2 g/da

(Level 2b) MMF dose during induction therapy should be 1.5–2 g/day. Duration of MMF treatment (i.e. before its discontinuation or replacement with AZA) should be at least 24 months when MMF used as induction immunosuppression. (Level 2b) Calcineurin inhibitors (in particular tacrolimus, check details on which there is more data) to be considered: a.  as induction therapy, in combination with corticosteroids, in patients who do not tolerate standard therapy such as MMF or CYC (Level 2b) Immunosuppressive treatment recommended for (pure) Class V LN when proteinuria ≥2 g/day. (Level 4) Monitoring of patients with active

disease should be no less frequent than every 2–4 weeks, until the patient shows a definite trend towards improvement. (Level 5) This category refers to patients with Class II (mesangial proliferative) LN. Most of these patients LEE011 present with non-nephrotic proteinuria without deterioration of renal function. Similar to the recommendations in the KDIGO guidelines, treatment is to include corticosteroid at a moderate dose with or without a well-tolerated immunosuppressive agent, the latter mainly for its steroid-sparing effect. The treatment response and progress of these patients should be closely monitored, as limited sampling from renal biopsy may miss more serious renal histology.

This refers to patients with Class III or Class IV LN (alone or in combination with Class V membranous features), or Class V LN with heavy proteinuria. These patients present with active urinary sediment (in the case of Class

III or IV LN), variable degree of proteinuria, with or without renal function impairment. Even if the serum creatinine is within the normal range, Ergoloid a decrease or deterioration in estimated glomerular filtration rate should alert the clinician to the possibility of severe nephritis. When there is practical difficulty in obtaining a renal biopsy, patients with microscopic haematuria and dysmorphic red cells, with or without red cell casts, an active lupus serology profile with high anti-dsDNA titres and evidence of complement activation such as low level of complement components, variable levels of proteinuria and renal function, should be considered to have severe nephritis and treated accordingly. In patients with renal biopsy prior to starting treatment, features indicating a need for more aggressive treatment include the presence of crescents, fibrinoid necrosis affecting the glomerular capillaries, and thrombotic microangiopathy. Reporting of renal biopsy findings according to the 2003 International Society of Nephrology / Renal Pathology Society (ISN/RPS) Classification of LN is standard practice.[69] Inter-observer variation remains a limitation of activity and chronicity indices,[70] and the inclusion of these indices in the renal biopsy report is variable but recommended. The severity of tubulo-interstitial fibrosis and tubular atrophy is a well-established prognostic indictor for renal survival.

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