Editorial

We are poised for a major advance in the treatment of lupus nephritis. Prior to 1960, the mortality rate for renal involvement was 80% within two years. After the availability of dialysis, this steadily improved. Nevertheless, by 1980, half with nephritis (and two-thirds with nephrotic syndrome) succumbed within 10 years. Between 1980 and the millennium, cyclosporine and mycophenolate mofetil became available. Along with advances in new antihypertensive agents (especially angiotensin converting enzyme inhibitors), improved antibiotics to treat infections, and transplant immunology, half with nephritis now survived 20 years. As pointed out by Dr. Mok in his update on the therapies for severe lupus nephritis in this issue, we still have a long way to go. More patients are surviving the initial onslaught of renal inflammation only to experience complications from chronic corticosteroid therapy and renal scarring (e.g., hypertension, hyperlipidemia, hyperglycemia). Over the last few years, lupus specialists have begun networking through collaborative groups (e.g., SLICC, the LCTC), forming registries, and following cohorts. This has led to publications showing that efforts to educate patients, eliminate nonadherence, increase access to lupus specialists, exercise programs, osteoporosis prevention measures, promotion of smoking cessation, weight reduction regimens, and aggressive proactive preventive efforts relating to accelerated atherogenesis can improve survival and quality of life without even considering the effects of anti-inflammatory regimens. The improvements in quality of life experienced by our lupus patients in the last few years has been bolstered by new insights into the etiopathogenesis of antiphospholipid syndrome as it relates to the kidney (e.g., using antiplatelet regimens in at risk patients), an improved classification system for nephritis (the ISN) which can better predict prognosis and the discovery of pro-inflammatory HDL in nephritis patients. Nevertheless, as reinforced in Dr Mok's review, using the "gold standard", cyclophosphamide, for proliferative lupus nephritis is still associated with a 50% risk of evolving end stage renal disease within 10 years if one considers "all comers". As briefly mentioned in his article, the advent of biologics have arrived. No fewer than 14 biologics are in clinical trials for SLE. Within the next year, nephritis studies evaluating abatacept and rituximab will join LJP 394 trials already underway. The publication of preliminary industry guidelines by the United States Food and Drug Administration and monitoring nephritis trials by the American College of Rheumatology further underscore the seriousness of these efforts. Hopefully, ten years from now when we reread Dr Mok's review, it will lead us to be thankful that new therapies being evolved at the present time were so much more effective.