Review

Protecting the kidneys in nephritis

Kidney involvement is common in systemic lupus erythematosus. The inciting event in is immune complex accumulation in the kidneys. While this immune process triggers damage in systemic lupus erythematosus, hemodynamic and metabolic factors activated after this initial event promote chronic, progressive damage to the kidney. Systemic and intraglomerular , , hyperlipidemia, hyperuricemia, uremic acidosis and vitamin D deficiency have all been found to contribute to the progression of . The aim of renal protective therapies is to suppress these secondary factors and thereby retard the progression of kidney disease in both active and inactive glomerular disease with residual . This can be effectively accomplished through a combination of medications, dietary interventions and lifestyle changes. The aim of this article is to discuss nonimmune therapies that will help retard the progression of kidney disease in lupus nephritis.

1 k eywords: glomerular disease n lupus n lupus nephritis n nephritis n proteinuria Samir Parikh , n renoprotection n SLE n systemic lupus erythematosus Lee Hebert1 & Brad Rovin†1 Kidney injury is common in systemic lupus all of these trials have been carried out in 1Division of , Department erythematosus (SLE). The most common chronic kidney disease (CKD) cohorts that of Internal Medicine, The Ohio State University Medical Center, Columbus, mechanism is immune complex accumulation did not include LN. Nevertheless, it is widely OH 43210, USA within the kidneys, followed by infiltration of believed that the outcomes of these CKD trials †Author for correspondence: Tel.: +1 614 293 4997 the kidney by T cells and macrophages, which are relevant to the management of LN. The Fax: +1 614 293 3073 induce the renal classified as notion is that combining the anti-inflammatory/ [email protected] lupus nephritis (LN) [1]. Unchecked, LN causes immunosuppressive therapies of LN with kidney progressive kidney damage. This progression, protective therapies of CKD will result in greater however, is not related only to the immune survival and reduce the risk that the LN complex accumulation. Indeed, there are now patients will be left with chronically impaired multiple lines of evidence that hemodynamic and kidney function (CKD). metabolic factors (nonimmune mechanisms) are There is now compelling evidence that also important participants in the progression CKD, even when mild, is a strong independent of LN. Furthermore, even when the immune risk factor for increased all-cause mortality, process subsides, these hemodynamic and particularly cardiovascular mortality. The need to metabolic factors may continue to cause avoid CKD is particularly strong in LN because progressive kidney damage [2]. generally SLE affects young adults. Thus, even The aim of this article is to discuss these though their LN may eventually be completely hemodynamic and metabolic mechanisms suppressed, patients left with CKD will have of kidney damage and how they can be prolonged exposure to the cardiovascular risks mitigated. These therapies are often referred associated with it. We suggest that the use of to collectively as ‘kidney protective therapy’. In kidney protective therapies in LN, along with general, these therapies are also cardiovascular the immunosuppression/anti-inflammatory protective. Specifically, patients with SLE have therapies, is essential to optimizing nephron a five- to six-fold increased risk for significan