{
  "abstract": "Renin-angiotensin-aldosterone system inhibitors (RAAS-I) (ACE inhibitors or ARBs) are the foundational nephroprotective therapy in lupus nephritis with persistent proteinuria, and should be initiated in all patients with proteinuria above the normal range, unless contraindicated 1 The American College of Rheumatology recommends their use in active, new-onset, or flare of lupus nephritis, regardless of proteinuria level, as long as blood pressure and eGFR permit. The Kidney Disease: Improving Global Outcomes (KDIGO) guideline also supports RAAS-I for proteinuria reduction in lupus nephritis.2 Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are now recommended for chronic kidney disease (CKD) of various etiologies, including glomerulonephritis, to reduce CKD progression and cardiovascular risk, regardless of diabetes status, provided eGFR is ≥20 mL/min/1.73 m². The KDIGO guideline recommends SGLT2i for adults with CKD, and emerging evidence supports their use in glomerulonephritis, including lupus nephritis, after stabilization of kidney function with immunosuppression and in conjunction with RAAS-I. SGLT2i should not be started during active lupus nephritis flares but may be considered once disease is quiescent and immunosuppression is stable. Observational data suggest SGLT2i may reduce the risk of lupus nephritis flares, dialysis, and mortality in systemic lupus erythematosus patients.3 4 Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are recommended for patients with CKD and type 2 diabetes to reduce albuminuria and slow eGFR decline, with cardiovascular benefit. The American Diabetes Association and KDIGO recommend GLP-1 RA in this context, but there is no evidence for their use in non-diabetic lupus nephritis.5 Mineralocorticoid receptor antagonists (MRA) (e.g., spironolactone, eplerenone, finerenone) may reduce proteinuria when added to RAAS-I, but their effect on hard renal outcomes in CKD is uncertain and they increase the risk of hyperkalemia and acute kidney injury. their use in lupus nephritis is not guideline-endorsed and should be individualised, with close monitoring.6 In summary, RAAS-I should be initiated at diagnosis of proteinuric LN, SGLT2i may be added after disease stabilization, and GLP-1 RA are reserved for those with type 2 diabetes. MRA use is not standard in lupus nephritis. Initiation of SGLT2i or MRA should be deferred during active immunosuppression or unstable kidney function. All nephroprotective therapies should be integrated with immunosuppression and individualized to patient risk and comorbidities.Learning Objectives At the end of this presentation participants will be able to:Explain that SGLT2i are increasingly recognised as nephroprotective agents in CKD, including glomerulonephritis, and may be considered in lupus nephritis patients with stable kidney function and after immunosuppression has controlled active diseaseRecognize that GLP-1 RA are recommended for nephroprotection primarily in patients with CKD and type 2 diabetes, but there is no evidence to support their use in non-diabetic lupus nephritisDescribe MRAs, particularly non-steroidal agents, may offer additional proteinuria reduction in CKD, but their use in lupus nephritis is not standard and should be individualised due to risks of hyperkalemia and acute kidney injuryReferences Sammaritano LR, Askanase A, Bermas BL, et al. 2024 American college of rheumatology (ACR) guideline for the screening, treatment, and management of lupus nephritis. Arthritis Rheumatol. 2025 doi: 10.1002/art.43212Rovin BH, Ayoub IM, Chan TM, et al. Executive summary of the KDIGO 2024 clinical practice guideline for the management of lupus nephritis. Kidney Int. 2024;105(1):31–34. doi: 10.1016/j.kint.2023.09.001Del Vecchio L, Peiti S, Pucci Bella G, et al. SGLT2 inhibitors in glomerulonephritis: Beyond nephroprotection? J Clin Med. 2025;14(10). doi: 10.3390/jcm14103533Ma KS, Lo JE, Kyttaris VC, et al. Efficacy and safety of sodium-glucose cotransporter 2 inhibitors for the primary prevention of cardiovascular, renal events, and safety outcomes in patients with systemic lupus erythematosus and comorbid type 2 diabetes: A population-based target trial emulation. Arthritis Rheumatol. 2025;77(4):414–22. doi: 10.1002/art.43037Natale P, Green SC, Tunnicliffe DJ, et al. Glucagon-like peptide 1 (GLP-1) receptor agonists for people with chronic kidney disease and diabetes. Cochrane Database Syst Rev. 2025;2(2):Cd015849. doi: 10.1002/14651858.CD015849.pub2Chung EY, Ruospo M, Natale P, et al. Aldosterone antagonists in addition to renin angiotensin system antagonists for preventing the progression of chronic kidney disease. Cochrane Database Syst Rev. 2020;10(10):Cd007004. doi: 10.1002/14651858.CD007004.pub4",
  "authors": [
    {
      "affiliations": [
        "Charité University Hospitals Berlin, Germany"
      ],
      "name": "Eva Schrezenmeier"
    }
  ],
  "title": "04 Nephroprotective therapies: which one and when to start? (SGLT2i, GLP-1, MRA)",
  "uid": "1051a3b8-7816-59f3-8487-63b2f0b9de07"
}