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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 ([1]). 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 ([2]), including those with lupus nephritis, in whom hydroxychloroquine helps to control renal activity ([3]). Indeed, withdrawal of hydroxychloroquine leads to an increase in flares ([4]), including in pregnant women ([5]). Thus, this drug should also be continued in those with inactive disease.

Second, women with previous renal disease are at high risk for preeclampsia ([6]). Moreover, lupus nephritis has also been specifically linked to this complication in a recent systematic review ([7]). 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 ([8]), and would similarly be recommended. Further, hydroxychloroquine reduced preeclampsia in a small trial in pregnant women with lupus ([9]).

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.

  • 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
    Ruiz-Irastorza G, Ramos-Casals M, Brito-Zeron P, Khamashta MA.Clinical efficacy and side effects of antimalarials in systemic lupus erythematosus: a systematic review.Ann Rheum Dis2010;69:208.
  • 3
    Kasitanon N, Fine DM, Haas M, Magder LS, Petri MA.Hydroxychloroquine use predicts complete renal remission within 12 months among patients treated with mycophenolate mofetil therapy for membranous lupus nephritis.Lupus2006;15:36670.
  • 4
    The Canadian Hydroxychloroquine Study Group.A randomized study of the effect of withdrawing hydroxychloroquine sulfate in systemic lupus erythematosus.N Engl J Med1991;324:1504.
  • 5
    Clowse ME, Magder L, Witter F, Petri MA.Hydroxychloroquine in lupus pregnancy.Arthritis Rheum2006;54:36407.
  • 6
    Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R.Pre-eclampsia.Lancet2010;376:63144.
  • 7
    Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD.A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis.Clin J Am Soc Nephrol2010;5:20608.
  • 8
    Askie LM, Duley L, Henderson-Smart DJ, Stewart LA, for the PARIS Collaborative Group.Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data.Lancet2007;369:17918.
  • 9
    Levy RA, Vilela VS, Cataldo MJ, Ramos RC, Duarte JL, Tura BR, et al.Hydroxychloroquine (HCQ) in lupus pregnancy: double-blind and placebo-controlled study.Lupus2001;10:4014.
  • 10
    Bertsias GK, Tektonidou M, Amoura Z, Aringer M, Bajema I, Berden JH, et al.Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis.Ann Rheum Dis2012;71:177182.
  • 11
    Ruiz-Irastorza G, Espinosa G, Frutos MA, Jimenez-Alonso J, Praga M, Pallares L, et al.Diagnosis 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 1:135.