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from the initial stages of diagnosing and evaluating the type of renal damage&#44; choosing the proper treatment&#44; and monitoring&#46; The essential objectives are to identify problems as early as possible and that can be prevented or treated as effectively as possible in order to achieve the highest level of remission for as long as possible&#46;</p><p class="elsevierStylePara">Several studies have been published in recent decades that have provided new and sometimes highly awaited and important pieces of evidence that have facilitated a personalised and effective treatment of patients with lupus nephritis&#44; with fewer complications&#46; This new panorama is driving important advancements in the quality and quantity of life of these patients by improving the control of the immunological activity of SLE and the recovery of deteriorated renal function&#46;</p><p class="elsevierStylePara">Renal involvement occurs in half of all patients with SLE&#44; and plays a very important role in this disease&#44; since it independently affects patient survival&#46; Therefore&#44; evaluating proteinuria&#44; urinary sediment&#44; and glomerular filtration rate must all be prioritised in patients with SLE&#44; both in the initial doctor&#8217;s visit and in subsequent check-ups&#46; Additionally&#44; a renal biopsy performed following established recommendations guarantees a precise evaluation of the type and extent of the renal damage&#44; justifying the choice of procedures that are not without risk&#46; The decision of which treatment to choose among the possible alternatives listed in the guidelines must be supported by individual clinical and pathological characteristics&#44; keeping in mind that the patient must not be under-treated &#40;greater risk of irreversible organ damage&#41; or over-treated &#40;more complications and greater severity&#41;&#46;</p><p class="elsevierStylePara">We have recently been able to understand some of the mechanisms involved in the development of lupus nephritis in the context of hyperactive B lymphocytes&#44; caused by an altered Lyn protein that usually regulates the activation of these B-cells&#46; Among the culprits are basophils and mast cells&#44; two of the cell lineages related to the pathogenesis that involves Th2 lymphocytes&#46;<span class="elsevierStyleSup">2</span> These are major advancements in determining the origin of the disease and identifying therapeutic targets&#46;</p><p class="elsevierStylePara">As one of the most notable milestones in the treatment of lupus nephritis&#44; we must mention cyclophosphamide pulses along with steroids&#46; The widespread use of this treatment allowed for reaching a higher rate of remission&#44; both of lupus disease in general and renal damage in particular&#46; Currently&#44; any treatment that might act as an alternative to cyclophosphamide must first prove that it does not have inferior potency or efficacy and that it can provide additional advantages to cyclophosphamide&#44; at least in three of the areas where we still need to make progress&#58; adverse effects&#44; recurrence&#44; and unresponsive patients&#46; Although we have reached high levels of remission using cyclophosphamide&#44; the price of the treatment and the rates of recurrence are very high and oblige us to maintain patients on immunosuppressants for long periods of time&#44; sometimes lifelong&#46;</p><p class="elsevierStylePara">Fortunately&#44; several well designed studies with control groups have produced therapeutic advancements in this field&#46; Firstly&#44; the discovery that induction doses of cyclophosphamide during shorter time periods were capable of achieving the same efficacy&#44; even at lower doses&#44;<span class="elsevierStyleSup">3&#44;4</span> which opened the door for more recent developments&#46; This yielded mycophenolate &#40;a &#8220;friendly&#8221; drug following successes in kidney transplants&#41; as an alternative to cyclophosphamide&#44; both in induction<span class="elsevierStyleSup">5</span> and maintenance<span class="elsevierStyleSup">6&#44;7 </span>phases&#44; for the majority of patients with lupus nephritis&#46; It offers some advantages over azathioprine in efficacy&#44; interval between recurrences&#44; and time to salvage therapy&#46;</p><p class="elsevierStylePara">In the chapter on resistance to cyclophosphamide and mycophenolate&#44; the guidelines describe where a repeated renal biopsy might be performed to search for changes and where administering immunosuppression along with triple therapy&#46; It also underscores that some patients may respond well to lymphocyte-depleting biological agents&#44; calcineurin inhibitors&#44; or immunoglobulins&#44; where evidence in support is still not so well established&#46; In these situations&#44; the recommendations are still a source of controversy&#44; probably due to the heterogeneity of clinical presentations and several other factors that may influence the disparity in patient responses&#46;</p><p class="elsevierStylePara">When the experience gained in treating patients with lupus nephritis is measured in decades instead of years&#44; certain precautions take on much greater importance&#46; In this sense&#44; the guidelines clearly take into account the current policy of steroid saving&#44; a strategy that must always influence our therapeutic recommendations since&#44; once reaching the chronic stage of the disease&#44; we must imagine the patient after 20 or more years of treatment&#46; Along this same line&#44; concomitant treatment with anti-proteinuria drugs has gained major importance&#44; especially in patients with resistant or residual proteinuria&#44; which we now know is never innocuous&#44; and the lower&#44; the better&#46; If we only consider the kidney and its alterations&#44; we lose perspective and objectivity regarding protection against cardiovascular risk and bone damage&#44; hindering an overall therapeutic approach to patients with SLE&#46; Whenever possible&#44; we should take a multidisciplinary approach to treatment&#44; since this type of collaboration provides major advantages in disease prevention &#40;arteriosclerosis&#44; prophylaxis against infections&#44; and bone and joint complications&#41; and under certain circumstances &#40;renal failure&#44; gestation&#44; and anti-phospholipid syndrome&#41;&#44; even in patients with apparently good levels of remission of nephritis and SLE&#46;</p><p class="elsevierStylePara">The consensus document also includes a number of recommendations for special situations&#44; including actions to take in advanced stages of chronic kidney disease and possibilities for renal replacement therapy&#44; which will be needed in almost 20&#37; of all patients with lupus nephritis&#44;<span class="elsevierStyleSup">8</span> a complication that currently does not prevent reaching good results with different dialysis treatments or kidney transplant&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">When we speak of the future&#44; we always imagine new drugs that will be better at treating lupus nephritis&#44; and without a doubt&#44; this is the most promising avenue for development&#46; This is the field where we have experienced the greatest progress in the past and so should it be in the future&#44; although we must keep in mind already existing drugs&#44; such as anti-malarial medications&#44; which are now employed as concomitant treatments&#46; The drugs that will constitute the future therapeutic arsenal against lupus nephritis will be much closer to the ideal&#44; since they will focus on specific targets and produce fewer side effects&#46; These treatments will be adjusted for each individual and level of renal involvement&#46; With the aid of biological markers&#44; we will be able to better determine the severity of the disease and response to treatment than using proteinuria levels&#44; urinary sediment&#44; and creatinine clearance&#46; We will also be able to better distinguish between a flare of lupus activity and other non-immunological processes that involve organ damage&#46; Although this currently seems like a complicated task&#44; it is close to being a reality&#46;</p><p class="elsevierStylePara">With these ambitious objectives&#44; the SEMI-SEN guidelines for the diagnosis and treatment of lupus nephritis should provide a useful tool that facilitates decision- making&#44; supported by the best evidence currently available&#44; with idea that the present and future condition of patients with lupus nephritis can be undoubtedly better&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p>"
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Lupus nephritis: in search of a better future
Nefritis lúpica: en busca de un futuro mejor
Miguel Á. Frutosa, Manuel Pragab, Carlos Queredac, Francisco Riverad, Alfons Segarrae
a Servicio de Nefrología, Hospital Regional Universitario Carlos Haya, Málaga,
b Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid,
c Servicio de Nefrología, Cochrane Renal Group. Grupo de MBE de la SEN. Hospital Universitario Ramón y Cajal, Madrid,
d Servicio de Nefrología, Hospital General Universitario de Ciudad Real, Ciudad Real,
e Servicio de Nefrología, Hospital Universitari Vall d'Hebron, Barcelona,
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from the initial stages of diagnosing and evaluating the type of renal damage&#44; choosing the proper treatment&#44; and monitoring&#46; The essential objectives are to identify problems as early as possible and that can be prevented or treated as effectively as possible in order to achieve the highest level of remission for as long as possible&#46;</p><p class="elsevierStylePara">Several studies have been published in recent decades that have provided new and sometimes highly awaited and important pieces of evidence that have facilitated a personalised and effective treatment of patients with lupus nephritis&#44; with fewer complications&#46; This new panorama is driving important advancements in the quality and quantity of life of these patients by improving the control of the immunological activity of SLE and the recovery of deteriorated renal function&#46;</p><p class="elsevierStylePara">Renal involvement occurs in half of all patients with SLE&#44; and plays a very important role in this disease&#44; since it independently affects patient survival&#46; Therefore&#44; evaluating proteinuria&#44; urinary sediment&#44; and glomerular filtration rate must all be prioritised in patients with SLE&#44; both in the initial doctor&#8217;s visit and in subsequent check-ups&#46; Additionally&#44; a renal biopsy performed following established recommendations guarantees a precise evaluation of the type and extent of the renal damage&#44; justifying the choice of procedures that are not without risk&#46; The decision of which treatment to choose among the possible alternatives listed in the guidelines must be supported by individual clinical and pathological characteristics&#44; keeping in mind that the patient must not be under-treated &#40;greater risk of irreversible organ damage&#41; or over-treated &#40;more complications and greater severity&#41;&#46;</p><p class="elsevierStylePara">We have recently been able to understand some of the mechanisms involved in the development of lupus nephritis in the context of hyperactive B lymphocytes&#44; caused by an altered Lyn protein that usually regulates the activation of these B-cells&#46; Among the culprits are basophils and mast cells&#44; two of the cell lineages related to the pathogenesis that involves Th2 lymphocytes&#46;<span class="elsevierStyleSup">2</span> These are major advancements in determining the origin of the disease and identifying therapeutic targets&#46;</p><p class="elsevierStylePara">As one of the most notable milestones in the treatment of lupus nephritis&#44; we must mention cyclophosphamide pulses along with steroids&#46; The widespread use of this treatment allowed for reaching a higher rate of remission&#44; both of lupus disease in general and renal damage in particular&#46; Currently&#44; any treatment that might act as an alternative to cyclophosphamide must first prove that it does not have inferior potency or efficacy and that it can provide additional advantages to cyclophosphamide&#44; at least in three of the areas where we still need to make progress&#58; adverse effects&#44; recurrence&#44; and unresponsive patients&#46; Although we have reached high levels of remission using cyclophosphamide&#44; the price of the treatment and the rates of recurrence are very high and oblige us to maintain patients on immunosuppressants for long periods of time&#44; sometimes lifelong&#46;</p><p class="elsevierStylePara">Fortunately&#44; several well designed studies with control groups have produced therapeutic advancements in this field&#46; Firstly&#44; the discovery that induction doses of cyclophosphamide during shorter time periods were capable of achieving the same efficacy&#44; even at lower doses&#44;<span class="elsevierStyleSup">3&#44;4</span> which opened the door for more recent developments&#46; This yielded mycophenolate &#40;a &#8220;friendly&#8221; drug following successes in kidney transplants&#41; as an alternative to cyclophosphamide&#44; both in induction<span class="elsevierStyleSup">5</span> and maintenance<span class="elsevierStyleSup">6&#44;7 </span>phases&#44; for the majority of patients with lupus nephritis&#46; It offers some advantages over azathioprine in efficacy&#44; interval between recurrences&#44; and time to salvage therapy&#46;</p><p class="elsevierStylePara">In the chapter on resistance to cyclophosphamide and mycophenolate&#44; the guidelines describe where a repeated renal biopsy might be performed to search for changes and where administering immunosuppression along with triple therapy&#46; It also underscores that some patients may respond well to lymphocyte-depleting biological agents&#44; calcineurin inhibitors&#44; or immunoglobulins&#44; where evidence in support is still not so well established&#46; In these situations&#44; the recommendations are still a source of controversy&#44; probably due to the heterogeneity of clinical presentations and several other factors that may influence the disparity in patient responses&#46;</p><p class="elsevierStylePara">When the experience gained in treating patients with lupus nephritis is measured in decades instead of years&#44; certain precautions take on much greater importance&#46; In this sense&#44; the guidelines clearly take into account the current policy of steroid saving&#44; a strategy that must always influence our therapeutic recommendations since&#44; once reaching the chronic stage of the disease&#44; we must imagine the patient after 20 or more years of treatment&#46; Along this same line&#44; concomitant treatment with anti-proteinuria drugs has gained major importance&#44; especially in patients with resistant or residual proteinuria&#44; which we now know is never innocuous&#44; and the lower&#44; the better&#46; If we only consider the kidney and its alterations&#44; we lose perspective and objectivity regarding protection against cardiovascular risk and bone damage&#44; hindering an overall therapeutic approach to patients with SLE&#46; Whenever possible&#44; we should take a multidisciplinary approach to treatment&#44; since this type of collaboration provides major advantages in disease prevention &#40;arteriosclerosis&#44; prophylaxis against infections&#44; and bone and joint complications&#41; and under certain circumstances &#40;renal failure&#44; gestation&#44; and anti-phospholipid syndrome&#41;&#44; even in patients with apparently good levels of remission of nephritis and SLE&#46;</p><p class="elsevierStylePara">The consensus document also includes a number of recommendations for special situations&#44; including actions to take in advanced stages of chronic kidney disease and possibilities for renal replacement therapy&#44; which will be needed in almost 20&#37; of all patients with lupus nephritis&#44;<span class="elsevierStyleSup">8</span> a complication that currently does not prevent reaching good results with different dialysis treatments or kidney transplant&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">When we speak of the future&#44; we always imagine new drugs that will be better at treating lupus nephritis&#44; and without a doubt&#44; this is the most promising avenue for development&#46; This is the field where we have experienced the greatest progress in the past and so should it be in the future&#44; although we must keep in mind already existing drugs&#44; such as anti-malarial medications&#44; which are now employed as concomitant treatments&#46; The drugs that will constitute the future therapeutic arsenal against lupus nephritis will be much closer to the ideal&#44; since they will focus on specific targets and produce fewer side effects&#46; These treatments will be adjusted for each individual and level of renal involvement&#46; With the aid of biological markers&#44; we will be able to better determine the severity of the disease and response to treatment than using proteinuria levels&#44; urinary sediment&#44; and creatinine clearance&#46; We will also be able to better distinguish between a flare of lupus activity and other non-immunological processes that involve organ damage&#46; Although this currently seems like a complicated task&#44; it is close to being a reality&#46;</p><p class="elsevierStylePara">With these ambitious objectives&#44; the SEMI-SEN guidelines for the diagnosis and treatment of lupus nephritis should provide a useful tool that facilitates decision- making&#44; supported by the best evidence currently available&#44; with idea that the present and future condition of patients with lupus nephritis can be undoubtedly better&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p>"
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Article information
ISSN: 20132514
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2022 September 30 26 56
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2022 July 19 43 62
2022 June 39 32 71
2022 May 25 27 52
2022 April 29 43 72
2022 March 40 37 77
2022 February 28 47 75
2022 January 31 24 55
2021 December 34 33 67
2021 November 25 34 59
2021 October 30 36 66
2021 September 21 30 51
2021 August 21 39 60
2021 July 29 25 54
2021 June 22 18 40
2021 May 25 23 48
2021 April 62 54 116
2021 March 43 31 74
2021 February 22 19 41
2021 January 17 16 33
2020 December 20 14 34
2020 November 27 6 33
2020 October 21 12 33
2020 September 8 5 13
2020 August 30 11 41
2020 July 24 6 30
2020 June 24 10 34
2020 May 18 9 27
2020 April 20 20 40
2020 March 26 8 34
2020 February 30 19 49
2020 January 31 15 46
2019 December 26 20 46
2019 November 29 12 41
2019 October 17 7 24
2019 September 19 27 46
2019 August 15 16 31
2019 July 23 17 40
2019 June 22 9 31
2019 May 20 10 30
2019 April 46 26 72
2019 March 33 19 52
2019 February 19 21 40
2019 January 21 17 38
2018 December 82 39 121
2018 November 144 20 164
2018 October 149 20 169
2018 September 71 14 85
2018 August 103 15 118
2018 July 65 19 84
2018 June 58 9 67
2018 May 71 18 89
2018 April 75 15 90
2018 March 71 12 83
2018 February 89 13 102
2018 January 70 13 83
2017 December 58 13 71
2017 November 45 9 54
2017 October 36 9 45
2017 September 32 14 46
2017 August 23 9 32
2017 July 24 19 43
2017 June 35 13 48
2017 May 36 20 56
2017 April 40 12 52
2017 March 20 25 45
2017 February 21 24 45
2017 January 29 22 51
2016 December 70 11 81
2016 November 91 21 112
2016 October 93 18 111
2016 September 142 8 150
2016 August 223 7 230
2016 July 188 17 205
2016 June 136 0 136
2016 May 133 0 133
2016 April 111 0 111
2016 March 86 0 86
2016 February 108 0 108
2016 January 120 0 120
2015 December 124 0 124
2015 November 87 0 87
2015 October 82 0 82
2015 September 76 0 76
2015 August 77 0 77
2015 July 63 0 63
2015 June 46 0 46
2015 May 43 0 43
2015 April 6 0 6
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?