Optimal glucocorticoid therapy in lupus nephritis.
Glucocorticoids remain a cornerstone of lupus nephritis treatment, but optimal dosing is still uncertain; practice has shifted from high-dose regimens toward lower doses combined with immunosuppressants to limit adverse effects, while low-dose and glucocorticoid-free regimens show promise but need further study.
Background
Lupus nephritis (LN) is a severe manifestation of systemic lupus erythematosus that affects up to 51.7% of patients and significantly increases the risk of mortality and progression to end-stage kidney disease. Glucocorticoids have been central to LN treatment for decades because of their anti-inflammatory properties, yet the optimal dosing strategy remains uncertain. This narrative review traces the historical evolution of glucocorticoid use in LN and describes their mechanisms of action through genomic and non-genomic pathways that modulate immune responses and metabolism.
Key findings
The review describes a shift from high-dose glucocorticoid regimens to combined approaches that pair immunosuppressants with lower glucocorticoid doses. It examines the evidence for different dosing strategies, including intravenous pulse therapy and oral regimens, in terms of efficacy and safety. Alternative approaches, such as low-dose and glucocorticoid-free regimens, are presented as promising but not yet sufficiently studied.
Safety
Long-term glucocorticoid use is associated with risks including infection, osteoporosis, hyperglycaemia and cardiovascular disease. Minimising these adverse effects is the main driver behind the move toward lower-dose and steroid-sparing combination regimens.
Clinical implications
Glucocorticoids remain a cornerstone of LN management despite their toxicity. The authors call for future research to optimise glucocorticoid regimens, refine tapering protocols and identify safer therapeutic combinations before low-dose or glucocorticoid-free strategies can be broadly adopted.
Category
Transplant
Source
Nephrol Dial Transplant
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