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.