The American College of Rheumatology (ACR) released its 2024 guidelines for screening, treating, and managing lupus nephritis. Approved by the ACR Board of Directors, the guidelines include 28 graded recommendations—7 strong and 21 conditional—along with 13 ungraded consensus-based good practice statements.

Key Recommendations

The guidelines highlight triple immunosuppressive therapy, which combines:

• Glucocorticoids (GC),
• Mycophenolic acid analogs (MPAA), and
• Either belimumab or calcineurin inhibitors (CNI).

For patients with active Class III/IV lupus nephritis, MPAA-based regimens were conditionally recommended over cyclophosphamide (CYC). Patients with proteinuria ≥3 g/g are advised to use a triple immunosuppressive regimen including MPAA and CNI. The Euro Lupus Nephritis Trial (ELNT) low-dose CYC is an additional option for some regimens, with MPAA replacing CYC after completion.

Treatment Duration and Monitoring

The guidelines recommend a treatment duration of 3-5 years for patients achieving complete renal response, with glucocorticoid dosing targeted at ≤5 mg/day by 6 months. Monitoring recommendations include:

• Quantifying proteinuria at least every 3 months in those without a complete renal response,
• Monitoring proteinuria every 3-6 months in patients with sustained complete renal response.

Additionally, regular measurement of serum complement levels and anti-dsDNA antibodies is advised.

Screening and Biopsy Recommendations

Screening for proteinuria every 6-12 months is recommended for people with systemic lupus erythematosus (SLE) without kidney disease. Kidney biopsy is advised for patients with proteinuria >0.5 g/g and/or unexplained impaired kidney function. Repeat biopsy is conditionally recommended for lupus nephritis (LN) flare or non-response after six months of therapy.

Special Populations

Pediatric Patients

The guidelines suggest reducing glucocorticoid regimens to pediatric-appropriate doses to minimize cumulative toxicity. Monitoring for delayed pubertal onset and decreased growth velocity is emphasized, with recommendations for structured transition to adult care.

Elderly Patients

Assessment of polypharmacy risks and regular evaluation of age-related glomerular filtration rate decline are prioritized.

End-Stage Kidney Disease

For patients approaching end-stage kidney disease (ESKD), kidney transplantation is recommended over dialysis. Preemptive kidney transplantation is conditionally advised for those nearing an eGFR of 15 mL/min/1.73m².

Adjunctive Treatments

The guidelines underscore the importance of systemic anticoagulation for patients at risk of thrombosis, such as those with severe proteinuria and low serum albumin. Non-immunologic therapies, including cardiovascular, bone, and infection management, are also highlighted.

Non-Responsive or Refractory LN

For patients with non-responsive LN, escalation to triple therapy or the addition of an anti-CD20 agent (e.g., rituximab) is recommended. Refractory cases may require a more intensive regimen, including triple non-glucocorticoid immunosuppressives or investigational therapies.

Collaborative Care and Equity

The ACR emphasized the need for collaborative care between rheumatologists and nephrologists and shared decision-making to address health disparities and improve outcomes.