KDIGO 2024版狼疮肾炎治疗临床实践指南（附表）.docx

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1、KDIGO 2024版狼疮肾炎治疗临床实践指南（附表）2021年，改善全球肾脏病预后组织（KDIGO ）发布了肾小球疾病治疗临 床实践指南，其中包括了狼疮肾炎（LN ）。2024年1月3日，KDlGO 发布了最新的LN治疗临床实践指南，本次更新考虑了自2022年2月以 来发表的随机对照研究的证据。本次更新包括了 LN的诊断、治疗和特殊 情况。LN的诊断LN诊断的方法如图1所示。NoYesNoYesNo further urinetesting at this timeQuantify proteinuriaNo further kidney functiontesting at this ti

2、meRepeat testingIs 24-hour proteinuria500 mg/d?NoIYesRepeat testing andfollow the progressNoConsider kidney biopsyNo further urinetesting at this time治疗1 .除非有禁忌症，所有系统性狼疮(SLE )以及LN患者都应接受羟氯噬 的治疗(IC)02 .应该考虑对LN进行管理，减轻LN疾病或其并发症：心血管疾病风险：生活方式管理，如减重、加强锻炼、戒烟等；血脂管 理；孕期接受小剂量阿司匹林管理；血压管理。蛋白尿与慢性肾脏病(CKD):避免高钠饮食；血

3、压管理；肾脏保护作 用的药物，如肾素血管紧张素醛固酮系统阻滞剂(RAASi)、钠葡萄糖共 转运蛋白2抑制剂SGLT-2i痔避免肾毒性药物 预防急性肾损伤AKI1 感染风险评估带状疱疹和肺结核病史；筛查HBVs HCV、HIV和HBV , 并接种相关疫苗；预防乙肝肺囊虫；个体化评估流感及肺炎球菌疫苗重组 带状疱疹疫苗的接种事宜；在考虑接种时，除了考虑个体情况，还应考虑 公共卫生的状况。骨损伤：SLE以及LN患者应接受骨密度与骨折风险评估；个体化补充 钙与维生素D以及使用双磷酸盐。紫外线照射：全身防晒霜涂抹、限制紫外线照射。卵巢早衰：促性腺激素释放激素激动剂；精子/卵母细胞冷冻。非计划妊娠：避孕咨

4、询。癌症：个体评估癌症发生风险；年龄特异性肿瘤筛查；减少环磷酰胺的 暴露(25(Ld-1.0 mg/kg (max 80 mg)0.6-0.7 mg/kg30 mg25 mg20 mg15 mg125 mgIOmg75 mg75 mg5 mg5 mg0.6-0.7 mg/kg (max 50 mg)05-0.6 mg/kg20 mg15 mg125 mg10 mg75 mg75 mg5 mg5 mg5 mg5 mg05-0.6 mg/kg (max 40 mg) 03-0.4 mg/kg15 mg IOmg 75 mg 5 mg 2.5 mg 25 mg 25 mg 25 mg 25 mg s

5、uppressive regimensLowdose glucocorticoids ANDMycophenolic add analogsAzathioprineBelimumab andCNI and mycophenolicmycophenolk acidadd analogsanalogs OraZathi OPrineCNI (such as vodosporin, tacrolimus or cyclosporine)MizoribineCommentsPreferred treatment based on high- certainty evidence; lower flar

6、e rate than azathioprine maintenanceLow medication cost; safe in pregnancyEfficacy and safety ofEffiocy and safety ofbelimumab demonstrated Voclosporin demonstrated in BLlSS-LN (104-wk) and in AURORA 1 (S2wk) and open4abel extensionAURORA 2 continuation trialstrials (28*wk)(2-y); efficacy and safety

7、 of(Practice Point 10.2.323 tacrolimus demonstrated in Multitarget Therap/trial in Chinese patients in which tacrolimus and reduceddose MPAA were given for 24 months (Practice POintlo2325Tacrolimus and Cydospcxine safe in pregnancy; insufficient pregnancy data on voclosporinExperience mostly in Japa

8、nese patients图4 III/IV LN维持期的药物联用方法7 . V型LN患者的治疗方案参见图5Kidney biopsyshowing Class V lupus nephritisLow-level proteinuriaNephrotic-range proteinuria1 Renin-angiotensin system blockade and blood pressure control2 Immunosuppressive treatment guided by extrarenal manifestations of systemic lupus erythema

9、tosus3 HydroxychloroquineMonitor the level of proteinuria and prevent or treatcomplications (e.g., thrombosis, dyslipidemia, edema)1 Renin-angiotensin system blockade and blood pressure control2 Combined immunosuppressive treatment with glucocorticoid and one other agent (e.g., mycophenolic add anal

10、ogs, cyclophosphamide, Calcineurin inhibitor, rituximab, azathioprine). Insufficient data for recommendation Ofglucocorticoid regimen, but moderate or reduced dose preferred. Please refer to Practice Point 10.23.1.1.3 HydroxychloroquineIf proteinuria worsens and/or complicationsof proteinuria develo

11、p (e.g., thrombosis,dyslipidemia, edema), considerimmunosuppressive therapy图5 V型LN患者的治疗方案8.LN患者对治疗的反应可分为完全缓解（CR ）、主要肾脏反应（Primary efficacy renal response ）、部分缓解（PR ）和无肾脏反应，其定义如下 图（图6 ）所示。CriteriaDefinitionComplete response* Reduction in proteinuria 0.5 g/g (50 mg/mmol) measured as the PCR from a24-h urine collection Stabilization or improvement in kidney function (10%-15% of baseline)