To the Editor:

After reading the interesting guidelines by Hahn et al for screening, treatment, and management of lupus nephritis (LN) recently published in Arthritis Care & Research (1), we want to share some comments with the authors on behalf of the Kidney and Pregnancy Group of the Italian Nephrology Society (2, 3) and give our personal expertise gained over 40 years in this setting (4–14). While we completely agree with the conclusion made by rheumatologists in another study that “more communication between different specialists caring for systemic lupus erythematosus (SLE) is needed” (15), we would like to take this opportunity to raise an interdisciplinary issue concerning recommendations for pregnancy in patients with LN.

In section X and Figure 4 of the guidelines, where recommendations for the treatment of LN in patients who are pregnant are detailed, there are two points that deserve to be discussed. The first point is that the 3 possible settings of pregnancy in patients with “no evidence of disease activity,” “mild disease activity,” or “clinically active LN” are described at the same level of the algorithm as if each was equally plausible, representing normal scenarios. There is no mention of the widely suggested option of waiting for at least 6 months of disease remission before planning pregnancy. Some examples from the literature include: “the best prevention of SLE flares during pregnancy is the delay of conception until a woman has had quiescent SLE for at least 6 months” (16), “pregnancy should be planned in advance, following a pre-conception visit in which the specific risk for complications can be assessed and pregnancy should be discouraged in women with recent serious lupus activity” (17), and “the outcomes of lupus pregnancies are better if conception is delayed until the disease has been inactive for at least 6 months, and the medication regimen has been adjusted in advance” (18). In fact, in the third scenario of pregnancy during “clinically active LN,” pregnancy may progress, but often with a high price to be paid for both the mother and baby (16–24).

The second point to be stressed is that, although controversial, the risk for flares not only during pregnancy but mainly in the postpartum period (17, 18, 20) should be a matter of concern. Immune–endocrine changes occurring during pregnancy might trigger a relapse of autoimmune diseases such as SLE through the activation of Th2 response (21, 22). Therefore, extending the specific monitoring of both renal and extrarenal flares until the postpartum period should have been emphasized as an important point.

On this basis, we think that these two concepts should be more clearly stated within the specific section regarding pregnancy and LN. Although planning pregnancy is not feasible in many situations, and also because SLE does not affect fertility, we believe that prepregnancy counseling of women with LN remains a crucial target to aim for (23). Therefore, in our view, a recommendation that, as stated elsewhere, “contraception and the need to plan any pregnancy are discussed regularly during the routine care of the patients” (24) should be included in the text of the guidelines before dealing with the management of pregnancy with clinically active LN. This would make it clear that the latter is a dangerous path and not a viable option; the clinician should make the patient aware of the increased risks this option entails as compared to a quiescent immunologic situation, and to discourage the patient from an unplanned pregnancy.

  • 1
    Hahn BH, McMahon MA, Wilkinson A, Wallace WD, Daikh DI, FitzGerald JD, et al. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken) 2012; 64: 797808.
  • 2
    Linee Guida della Società Italiana di Nefrologia: Rene e Gravidanza. URL: http:/
  • 3
    Stratta P, Canavese C, Lupo A, Pozzi C, Passerini P, Cagnoli L, et al. Treating lupus nephritis: guideline from the Italian Society of Nephrology. G Ital Nefrol 2007; 24 Suppl 37: 5063.
  • 4
    Stratta P, Canavese C, Quaglia M. Pregnancy in patients with kidney disease. J Nephrol 2006; 19: 13543.
  • 5
    Stratta P, Mesiano P, Campo A, Grill A, Ferrero S, Santi S, et al. Life expectancy of women with lupus nephritis now approaches that of the general population. Int J Immunopathol Pharmacol 2009; 22: 113541.
  • 6
    Stratta P, Canavese C, Ciccone G, Rosso S. Relative survival of patients with lupus nephritis significantly improved over time in an Italian region: comment on the article by Faurschou et al [letter]. Arthritis Care Res (Hoboken) 2010; 62: 18123.
  • 7
    Stratta P, Cremona R, Lazzarich E, Quaglia M, Fenoglio R, Canavese C. Life-threatening systemic flare-up of systemic lupus erythematosus following influenza vaccination. Lupus 2008; 17: 678.
  • 8
    Stratta P, Canavese C, Fenoglio R, Priolo G, Grillo A, Aimo G, et al. Dual effect of methylprednsolone pulses on apoptosis of peripheral leukocytes in patients with renal diseases. Int J Immunopathol Pharmacol 2006; 19: 64759.
  • 9
    Stratta P, Canavese C, Giacchino F, Mesiano P, Quaglia M, Rossetti M. Pregnancy in kidney transplantation: satisfactory outcomes and harsh realities. J Nephrol 2003; 16: 792806.
  • 10
    Stratta P, Besso L, Canavese C, Grill A, Todros T, Benedetto C, et al. Is pregnancy-related acute renal failure a disappearing clinical entity? Ren Fail 1996; 18: 57584.
  • 11
    Stratta P, Canavese C, Dogliani M, Todros T, Gagliardi L, Vercellone A. Pregnancy-related acute renal failure. Clin Nephrol 1989; 32: 1420.
  • 12
    Stratta P, Canavese C, Colla L, Dogliani M, Gagliardi F, Todros T, et al. The role of intravascular coagulation in pregnancy related acute renal failure. Arch Gynecol Obstet 1988; 243: 20714.
  • 13
    Stratta P, Canavese C, Colla L, Dogliani M, Messina M, Gabella P, et al. Acute renal failure in obstetric complications. Biol Res Pregnancy Perinatol 1986; 7: 1137.
  • 14
    Stratta P, Canavese C, Valmaggia P, Rotunno M, Levi E, Bulla A, et al. Coagulation and fibrinolysis study in systemic lupus erythematosus: haematological, urinary and tissue parameters. Thromb Haemost 1981; 46: 57580.
  • 15
    Lerang K, Gilboe IM, Gran JT. Differences between rheumatologists and other internists regarding diagnosis and treatment of systemic lupus erythematosus. Rheumatology (Oxford) 2012; 51: 6639.
  • 16
    Clowse ME. Lupus activity in pregnancy. Rheum Dis Clin North Am 2007; 33: 23752.
  • 17
    Ruiz-Irastorza G, Khamashta MA. Managing lupus patients during pregnancy. Best Pract Res Clin Rheumatol 2009; 23: 5759.
  • 18
    Baer AN, Witter FR, Petri M. Lupus and pregnancy. Obstet Gynecol Surv 2011; 66: 63953.
  • 19
    Imbasciati E, Tincani A, Gregorini G, Doria A, Moroni G, Cabiddu G, et al. Pregnancy in women with pre-existing lupus nephritis: predictors of fetal and maternal outcome. Nephrol Dial Transplant 2009; 24: 51925.
  • 20
    Ruiz-Irastorza G, Khamashta MA. Lupus and pregnancy: integrating clues from the bench and bedside. Eur J Clin Invest 2011; 41: 6728.
  • 21
    Clowse ME. Managing contraception and pregnancy in the rheumatologic diseases. Best Pract Res Clin Rheumatol 2010; 24: 37385.
  • 22
    Doria A, Tincani A, Lockshin M. Challenges of lupus pregnancies. Rheumatology (Oxford) 2008; 47 Suppl 3: iii912.
  • 23
    Wagner SJ, Craici I, Reed D, Norby S, Bailey K, Wiste HJ, et al. Maternal and foetal outcomes in pregnant patients with active lupus nephritis. Lupus 2009; 18: 3427.
  • 24
    Day CJ, Lipkin GW, Savage CO. Lupus nephritis and pregnancy in the 21st century. Nephrol Dial Transplant 2009; 24: 3447.

Piero Stratta MD*, Marco Quaglia MD*, * Amedeo Avogadro University and Maggiore della Carità Hospital, Novara, Italy.