**7. Conclusion**

Emerging insights into the heterogenous immunopathogenesis of LN have lead to novel, tailored therapeutic options, resulting in significantly better disease control and prolonged remission among patients; nonetheless, more in-depth studies are required to better understand the pathogenesis while novel therapies continue to be tested. The advent of signature biomarkers show promise in diagnosis, evaluation and management of LN and will continue to be validated for meaningful real-world application. Timely diagnosis, prompt treat-to-target treatment, MDT approach and adherence to therapy are important factors to preserve renal function, prevent disease progression and significantly improve patients' overall outcome.

Better understanding of disease pathways and discoveries with subsequent validation of biomarkers will provide opportunity for improvement in early detection, prognostic and disease severity prediction, subgroups stratification, treatment adherence assessment, and decision for best treatment option in a timely manner. Studies targeting a single organ or specific subgroup with similar disease severity, duration and background SOC therapy will assist in better assesment of drug effectiveness and accelerate drug development in LN.

**49**

**Author details**

\* and Wan Ahmad Hafiz Wan Md Adnan<sup>2</sup>

\*Address all correspondence to: fahd\_adeeb@yahoo.com

provided the original work is properly cited.

1 Department of Rheumatology, University Hospital Kerry, Kerry, Ireland

2 Department of Nephrology, University Malaya, Kuala Lumpur, Malaysia

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Fahd Adeeb1

*Lupus Nephritis: Current Updates*

*DOI: http://dx.doi.org/10.5772/intechopen.96891*

*Lupus Nephritis: Current Updates DOI: http://dx.doi.org/10.5772/intechopen.96891*

*Lupus - Need to Know*

graft failure [137].

cases [139].

health [143].

**7. Conclusion**

used in both transplant recipient and active LN.

may not be in complete remission despite dialysis initiation, making preemptive transplantation difficult. Current guidelines suggest that clinical lupus activity and ideally, serologically should be quiescent for 6 months and on no or minimal immunosuppression prior to transplantation [47, 136]. Even if on dialysis, the waiting time for transplant should be maximally shortened to reduce potential risk of

Although the benefit of transplantation is clear, earlier studies have suggested that LN patients may have worse survival outcome compared to ESRD patients of other aetiologies; however, more contemporary studies seem to abrogate this finding [138]. Clinically relevant recurrence rate of SLE post transplantation is less than 5%, but it increases the risk of graft failure [136]. The rate may even be higher if electron microscopy finding is included and protocol biopsy implemented; nevertheless, the lower rate is probably due to the similar immunosuppressive therapy

During pre-transplant evaluation, particular attention should be given to screening of aPL as its' presence increases the risk of graft thrombosis. Patients with APS would require careful consideration of perioperative anticoagulation to prevent graft loss. Presence of anti-dsDNA or low complement level is not a predictor for renal transplant outcomes. SLE patients have higher risk for cardiovascular mortality hence will require careful cardiac evaluation prior to transplantation [138]. Recurrence of LN after transplantation can be treated by increasing the dose of the immunosuppressive drugs already being used post transplant. CYC may be considered in severe or aggressive disease while RTX has been used in resistant

There is concern in LN patients of having higher risk to develop cancer with prolonged exposure to immunosuppression. Previous exposure to CYC doubles the risk for cancer post transplantation, primarily of the skin [140]. Prior use of immunosuppressive therapies before transplant also increases the risk for non-Hodgkin's lymphoma, anogenital, breast, renal and bladder cancers [141, 142]. Furthermore, prolonged corticosteroid exposure in transplanted SLE patients should adhere to the screening and treatment recommendations on bone

Emerging insights into the heterogenous immunopathogenesis of LN have lead to novel, tailored therapeutic options, resulting in significantly better disease control and prolonged remission among patients; nonetheless, more in-depth studies are required to better understand the pathogenesis while novel therapies continue to be tested. The advent of signature biomarkers show promise in diagnosis, evaluation and management of LN and will continue to be validated for meaningful real-world application. Timely diagnosis, prompt treat-to-target treatment, MDT approach and adherence to therapy are important factors to preserve renal function, prevent disease progression and significantly improve patients' overall

Better understanding of disease pathways and discoveries with subsequent validation of biomarkers will provide opportunity for improvement in early detection, prognostic and disease severity prediction, subgroups stratification, treatment adherence assessment, and decision for best treatment option in a timely manner. Studies targeting a single organ or specific subgroup with similar disease severity, duration and background SOC therapy will assist in better assesment of drug

effectiveness and accelerate drug development in LN.

**48**

outcome.
