Beyond the trial: a single-center retrospective review of real-world lupus nephritis management and outcomes.

Background: Systemic lupus erythematosus (SLE) is a prevalent autoimmune disease affecting up to a quarter million Americans. Lupus nephritis (LN) is an immune complex glomerulonephritis that occurs when circulating immune complexes deposit in the kidney and is a common sequela of SLE. LN serves as a marker of disease severity and contributes significantly to mortality in SLE. Despite growing access to novel therapies, the disease burden remains high, and the gap between real-life challenges and clinical trial success persists. Our study is an effort to bridge the gap by examining factors such as diverse choice of immunosuppression, socioeconomic constraints, and adherence outside the carefully calibrated environment of clinical trials. Methods: We conducted a retrospective review of patients with biopsy proven LN to evaluate prognostic factors and treatment related complications at a tertiary hospital with patients selected from biopsy records obtained from January 2015 through December 2023. A total of 66 patients met inclusion criteria and were included in the final analysis of the cohort. Patients with findings other than confirmed LN and kidney transplant recipients were excluded. Longitudinal data were collected at 6 months, 12 months, 2 years, and 5 years after biopsy, and response to treatment was defined using Kidney Disease Improving Global Outcomes (KDIGO) 2024 clinical practice guidelines for LN. Results: Of the 163 kidney biopsy reports reviewed from January 2015 through December 2023, 66 were confirmed as LN and included in the analysis. The median age at biopsy was 35 years, 76% were women, and 62% were African American. At 6 months, 50% of Class I and II LN, 49% of Class III, IV, III + V and IV + V LN, and 83% of Class V LN had no response to treatment, without significant differences between classes or in terms of partial vs. complete response. At 12 months, 55% of Class I and II, 50% of Class III, IV, III + V, and IV + V, and 87% of Class V LN had no response to treatment, with a significant difference ( Conclusion: Our study provides practical and real-world data on management of LN. In patients with SLE, LN is associated with significant morbidity and mortality. Management continues to pose a unique challenge despite developing therapies. Sustained remission is often dependent on a complex interplay of individualized care, patient adherence, and socioeconomic factors. There is a need for increased awareness of LN as early biopsy, prompt initiation and continuation of treatment positively impacts outcomes.