Summary

KDIGO 2024 is a focused update of the lupus nephritis chapter from the 2021 Glomerular Diseases Guideline. The update incorporates the FDA/EMA approvals of belimumab and voclosporin as add-on immunosuppressive agents for LN. Recommendations follow GRADE methodology and are supplemented by expert practice points covering diagnosis, induction, maintenance, and special populations.

Key Recommendations

Perform kidney biopsy in SLE patients with otherwise unexplained kidney involvement (rising creatinine, proteinuria, active sediment) to classify by ISN/RPS criteria and guide therapy.
Treat all patients with LN with hydroxychloroquine unless contraindicated.
For active Class III/IV (± V) LN, initiate induction with glucocorticoids plus either mycophenolate mofetil (MMF) or low-dose IV cyclophosphamide (Euro-Lupus regimen).
Consider triple therapy with addition of belimumab or a calcineurin inhibitor (voclosporin or tacrolimus) to standard induction, particularly in patients at high risk of progression or with nephrotic-range proteinuria.
Use a reduced-dose oral glucocorticoid taper rather than traditional high-dose prednisone to minimize steroid toxicity.
Continue maintenance immunosuppression with MMF (preferred) or azathioprine for at least 36 months after achieving complete response; belimumab can be continued as add-on.
Treat pure Class V (membranous) LN with proteinuria above nephrotic range with immunosuppression plus antiproteinuric/supportive therapy; MMF is first-line.
Manage refractory/relapsing LN by reassessing adherence, considering repeat biopsy, and switching induction agent or adding belimumab, a CNI, or rituximab.
Provide supportive care with RAAS inhibition for proteinuria, BP control, cardiovascular risk reduction, and SGLT2 inhibitors in eligible patients with proteinuric CKD.
Counsel women of childbearing potential on contraception during cyclophosphamide and MMF exposure; switch to azathioprine, tacrolimus, or CNI-based regimens before pregnancy and continue hydroxychloroquine throughout pregnancy.
Do not use rituximab routinely as first-line induction; reserve for refractory disease or when standard agents are contraindicated.

Thresholds & Doses

Euro-Lupus cyclophosphamide induction: 500 mg IV every 2 weeks for 6 doses (total 3 g).
MMF induction target: ~2–3 g/day orally for 6 months.
Maintenance immunosuppression: continue ≥36 months after complete response before considering taper.
Reduced-dose prednisone induction: starting ~0.5 mg/kg/day (rather than 1 mg/kg/day) with rapid taper.
Hydroxychloroquine: ≤5 mg/kg/day to limit retinal toxicity.
Voclosporin: 23.7 mg orally twice daily (per FDA labeling referenced in guideline) added to MMF + glucocorticoids.
Complete renal response target: proteinuria <0.5 g/g creatinine with stable/improved eGFR.

Citations

KDIGO 2024 Lupus Nephritis Guideline, Executive Summary — overall scope and update from 2021.
Chapter on Treatment of Class III/IV LN — induction regimens including belimumab and voclosporin add-on.
Chapter on Class V LN — management of membranous lupus nephritis.
Practice Points on glucocorticoid dosing — reduced-dose prednisone taper.
Top 10 Takeaways for Clinicians (KDIGO 2024) — high-yield clinical recommendations.
Chapter on Maintenance Therapy — MMF/azathioprine duration ≥36 months.
Chapter on Special Populations — pregnancy, hydroxychloroquine continuation, drug safety.