Letters to the Editor
Managing Lupus Nephritis in Pregnant Women: Comment on the Article by Hahn et al
Article first published online: 26 JUL 2013
Copyright © 2013 by the American College of Rheumatology
Arthritis Care & Research
Volume 65, Issue 8, pages 1391–1392, August 2013
How to Cite
Ruiz-Irastorza, G., Petri, M., Gordon, C. and Khamashta, M. (2013), Managing Lupus Nephritis in Pregnant Women: Comment on the Article by Hahn et al. Arthritis Care Res, 65: 1391–1392. doi: 10.1002/acr.22004
- Issue published online: 26 JUL 2013
- Article first published online: 26 JUL 2013
- Accepted manuscript online: 12 MAR 2013 12:25PM EST
The American College of Rheumatology (ACR) guidelines for screening, treatment, and management of lupus nephritis published recently in Arthritis Care & Research included specific recommendations for the management of lupus nephritis in pregnant women (). For those with no evidence of active disease, no specific lupus therapy was recommended. Hydroxychloroquine was advised for patients with mild systemic activity and glucocorticoids with or without azathioprine for those with active nephritis or substantial extrarenal activity.
In our view, providing no therapy is not the best option for pregnant women with previous lupus nephritis. First, hydroxychloroquine is recommended for all patients with systemic lupus erythematosus who do not have contraindications (), including those with lupus nephritis, in whom hydroxychloroquine helps to control renal activity (). Indeed, withdrawal of hydroxychloroquine leads to an increase in flares (), including in pregnant women (). Thus, this drug should also be continued in those with inactive disease.
Second, women with previous renal disease are at high risk for preeclampsia (). Moreover, lupus nephritis has also been specifically linked to this complication in a recent systematic review (). Low-dose aspirin has been shown to significantly reduce the frequency of preeclampsia, the risk of delivery before 34 weeks, and serious adverse obstetric outcomes in high-risk women (), and would similarly be recommended. Further, hydroxychloroquine reduced preeclampsia in a small trial in pregnant women with lupus ().
Recently published guidelines by other scientific organizations recommended both hydroxychloroquine and low-dose aspirin for treating lupus nephritis in pregnant women ([10, 11]). It is our view that the ACR guidelines should be revised to include these recommendations.
- 7A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis.Clin J Am Soc Nephrol2010;5:2060–8., , , , , .
- 11Diagnosis and treatment of lupus nephritis: consensus document from the systemic auto-immune disease group (GEAS) of the Spanish Society of Internal Medicine (SEMI) and Spanish Society of Nephrology (S. E.N.).Nefrologia2012;32 Suppl 1:1–35., , , , , , et al.