Immunosuppression Protocols in Glomerular Disease

Evidence-based dosing, monitoring, and supportive care for immunosuppressive therapy in glomerulonephritis

KDIGO GN 2021 RAVE 2010 ALMS 2009 AURORA 2021 ADVOCATE 2021

Andrew Bland, MD, MBA, MS | University of Dubuque PA Program

1. Pulse Methylprednisolone

Dosing

Standard pulse: 500–1000 mg IV daily for 3 consecutive days
Infuse over 30–60 minutes in 100–250 mL normal saline
Typically followed by oral prednisone taper (see Section 2)

Indications

Condition	Typical Pulse Dose	Notes
Rapidly progressive GN (RPGN) / crescentic GN	1000 mg IV x 3 days	Start empirically before biopsy if clinical suspicion high; follow with cyclophosphamide or rituximab
Severe lupus nephritis (Class III/IV with crescents)	500–1000 mg IV x 3 days	Per KDIGO 2024 and ACR/EULAR lupus nephritis guidelines
Anti-GBM disease	1000 mg IV x 3 days	Combined with plasmapheresis and cyclophosphamide; dialysis-dependent patients with 100% crescents have poor renal prognosis
ANCA vasculitis with severe renal/pulmonary involvement	500–1000 mg IV x 3 days	Followed by oral taper; consider avacopan to reduce steroid exposure (ADVOCATE)

Monitoring During Pulse Therapy

Blood glucose: Check every 6 hours; insulin sliding scale often needed; hyperglycemia common even in non-diabetics
Blood pressure: Monitor closely; may cause acute hypertension
Infection surveillance: Ensure no active untreated infection before pulsing; hold if febrile
Electrolytes: Sodium retention and hypokalemia possible
Mental status: Steroid psychosis can occur with high-dose IV steroids; more common in elderly patients
Cardiac: Rare arrhythmias reported with rapid infusion; ensure adequate infusion time

Clinical Pearl: Do not delay pulse steroids in suspected RPGN while awaiting biopsy. Crescentic GN is a nephrology emergency — irreversible damage accrues within days to weeks.

2. Oral Prednisone Taper Schedules

Rapid Taper — RPGN / ANCA Vasculitis

Used after pulse methylprednisolone for severe disease. Goal: minimize cumulative steroid exposure while controlling active inflammation.

Weeks 1–2:Prednisone 1 mg/kg/day (max 60–80 mg/day) Weeks 3–4:40 mg/day Weeks 5–6:30 mg/day Weeks 7–8:20 mg/day Weeks 9–10:15 mg/day Weeks 11–12:10 mg/day Weeks 13–16:7.5 mg/day Weeks 17–20:5 mg/day Weeks 21–24:2.5 mg/day, then discontinue (or physiologic replacement if adrenal suppression suspected)

ADVOCATE Trial Insight: Avacopan (C5a receptor inhibitor) allowed a reduced-steroid regimen in ANCA vasculitis: prednisone starting at 60 mg tapered to 0 by week 21, with non-inferior remission rates and superior GFR recovery at week 52. PMID: 33596356

Standard Taper — Nephrotic Syndrome (MCD/FSGS)

Used for primary nephrotic syndromes. Duration depends on response.

Weeks 1–8:Prednisone 1 mg/kg/day (max 80 mg/day); assess for remission at 8 weeks Weeks 9–12:If in remission: 0.5 mg/kg every other day Weeks 13–16:Reduce by 5–10 mg every 2 weeks Weeks 17–20:10 mg every other day Weeks 21–24:5 mg every other day, then discontinue Total duration:~24 weeks (6 months); FSGS may require up to 16 weeks of full-dose before declaring steroid-resistant

Lupus Nephritis Taper (post-pulse)

Weeks 1–4:0.5–1 mg/kg/day (typically 40–60 mg/day) Month 2:Taper to 30 mg/day Month 3:Taper to 20 mg/day Month 4:Taper to 15 mg/day Month 5:Taper to 10 mg/day Month 6+:Taper to 5–7.5 mg/day; maintain low-dose long-term per rheumatology guidance; target ≤5 mg/day by 12 months

Steroid Adverse Effect Monitoring

Adverse Effect	Monitoring	Prevention / Management
Hyperglycemia / new-onset diabetes	Fingerstick glucose QID during pulse; fasting glucose and HbA1c monthly during taper	Insulin for inpatient; metformin or insulin outpatient; SGLT2i caution if nephrotic
Osteoporosis	DEXA at baseline if expected ≥3 months of therapy	Calcium 1000–1200 mg/day + vitamin D 800–1000 IU/day; bisphosphonate if T-score ≤−1.5 or prednisone ≥7.5 mg/day ≥3 months (see Section 8)
Avascular necrosis	Clinical: hip/knee pain; MRI if symptomatic	Minimize cumulative dose; early orthopedic referral
Infections (opportunistic)	PCP prophylaxis (see Section 9); HBV screening pre-treatment	TMP-SMX DS daily or 3x/week; monitor for CMV, fungal infections
Hypertension	BP at each visit	Sodium restriction; antihypertensives as needed
Cataracts / glaucoma	Ophthalmology referral if ≥6 months of therapy	Annual eye exam
Adrenal suppression	AM cortisol if on ≥3 months and tapering below 7.5 mg/day	Do not abruptly discontinue; taper to physiologic dose (5 mg prednisone = ~20 mg cortisol); stress-dose steroids for surgery/illness
Weight gain / Cushing features	Weight at each visit	Dietary counseling; exercise; minimize dose
Psychiatric effects	Screen for mood changes, insomnia, psychosis	Dose reduction; short-acting steroids; psychiatry referral if severe
GI effects (peptic ulcer)	Symptoms; consider H. pylori testing	PPI if concurrent NSAID use; avoid NSAIDs when possible
Myopathy	Proximal muscle weakness	Minimize dose; physical therapy

3. Cyclophosphamide

IV Pulse Protocols

Protocol	Dosing	Duration	Primary Indication
Euro-Lupus (low-dose)	500 mg IV every 2 weeks	6 doses (3 months)	Lupus nephritis Class III/IV; non-inferior to NIH protocol in European cohorts (PMID: 15846645)
NIH Protocol (high-dose)	0.5–1 g/m² IV monthly	6 months induction, then quarterly for 1–2 years (historical)	Severe proliferative lupus nephritis; higher toxicity but remains option for refractory disease
ANCA Vasculitis (CYCLOPS)	15 mg/kg IV (max 1.2 g) every 2–3 weeks	3–6 months induction	ANCA vasculitis with renal involvement; reduced cumulative dose vs. daily oral
Anti-GBM Disease	2–3 mg/kg/day oral (preferred) or pulse IV	2–3 months	Combined with plasmapheresis and steroids

Dose Adjustments

Renal impairment: Reduce dose by 25% if eGFR <25 mL/min; further adjust for dialysis patients
Age ≥60 years: Reduce dose by 25% (increased bone marrow toxicity)
Obesity: Use ideal body weight for BSA-based dosing

Monitoring

WBC nadir: Check CBC at day 10–14 after each dose; target WBC nadir >3,000/μL; absolute neutrophil count >1,500/μL
CBC before each dose: Hold if WBC <3,500/μL; dose-reduce by 25% if nadir WBC 2,000–3,000/μL
Urinalysis: Monitor for hemorrhagic cystitis (microscopic hematuria)
Hepatic function: LFTs at baseline and periodically

Hemorrhagic Cystitis Prevention

Mesna (2-mercaptoethanesulfonate): 20% of cyclophosphamide dose given at 0, 4, and 8 hours after IV cyclophosphamide
Aggressive IV hydration (2–3 L) on day of infusion
Encourage frequent voiding; void before bedtime
Morning administration preferred to allow daytime hydration and voiding

Fertility Preservation

GnRH agonists (leuprolide): Administer 10–14 days before first cyclophosphamide dose; continue monthly during treatment to suppress ovarian function
Sperm cryopreservation: Offer to all male patients of reproductive age before initiation
Oocyte/embryo cryopreservation: Consider if time permits before urgent treatment
Cumulative dose threshold: Risk of premature ovarian failure increases with cumulative dose >10 g and age >30 years

Malignancy Risk: Cumulative cyclophosphamide exposure increases long-term risk of bladder cancer, myelodysplastic syndromes, and lymphoma. Limit cumulative lifetime exposure when possible. Euro-Lupus protocol preferred over NIH for reduced toxicity.

4. Rituximab

Dosing Protocols

Protocol	Dosing	Indication	Key Trial Data
RAVE Protocol	375 mg/m² IV weekly x 4 doses	ANCA vasculitis induction	Non-inferior to cyclophosphamide for induction of remission; superior for relapsing disease (PMID: 20647199)
RITUXVAS Protocol	375 mg/m² IV weekly x 4 doses + 2 pulses IV cyclophosphamide (15 mg/kg) with doses 1 and 3	Severe renal vasculitis	Comparable remission and adverse event rates to standard cyclophosphamide (PMID: 20647198)
Rheumatoid arthritis dosing	1000 mg IV x 2 doses, 2 weeks apart	Used off-label for membranous nephropathy, lupus nephritis, frequently relapsing MCD/FSGS	MENTOR trial: non-inferior to cyclosporine for membranous nephropathy; superior sustained remission at 24 months (PMID: 31269364)
Maintenance	500 mg IV every 6 months	ANCA vasculitis maintenance (MAINRITSAN trial)	Superior to azathioprine for relapse prevention at 28 months (PMID: 25372085)

Pre-infusion Protocol

Acetaminophen 650–1000 mg PO
Diphenhydramine 50 mg IV or PO
Methylprednisolone 100 mg IV (or equivalent)
First infusion: start at 50 mg/hr, escalate by 50 mg/hr every 30 min to max 400 mg/hr
Subsequent infusions: may start at 100 mg/hr if prior infusion tolerated

Monitoring

B-cell depletion: CD19/CD20 count before each dose; verify depletion (<5 cells/μL) at 2 weeks post-infusion
Immunoglobulin levels: Quantitative IgG, IgA, IgM at baseline and every 6 months; hold rituximab if IgG <400 mg/dL and recurrent infections
IgG replacement: Consider IVIG or SCIG if IgG <300 mg/dL or recurrent serious infections with IgG <500 mg/dL
Infection screening: HBV serologies (HBsAg, anti-HBc, anti-HBs) mandatory before first dose; HBV reactivation risk is well-documented
JC virus / PML risk: Rare but devastating; counsel patients to report new neurological symptoms (cognitive changes, visual disturbances, motor weakness); no reliable screening test for JC virus; risk increases with prior immunosuppression and prolonged B-cell depletion
Vaccination timing: Complete vaccinations at least 4 weeks before rituximab; live vaccines contraindicated; response to vaccines is blunted for 6–12 months post-infusion

Hypogammaglobulinemia: Prolonged rituximab use causes cumulative IgG decline. The KDIGO 2021 GN guideline recommends checking immunoglobulins before each re-dosing cycle and holding if IgG is critically low with infections.

5. Mycophenolate Mofetil (MMF)

Key Trial Data

Trial	Comparison	Result
ALMS Induction (2009)	MMF 3 g/day vs. IV cyclophosphamide (NIH)	Similar response rates overall; MMF with fewer severe infections and amenorrhea (PMID: 19369404)
ALMS Maintenance (2011)	MMF vs. azathioprine for LN maintenance	MMF superior in preventing treatment failure (renal flare, rescue therapy needed) (PMID: 22087680)
IMPROVE (2010)	MMF vs. azathioprine for ANCA vasculitis maintenance	MMF inferior to azathioprine for relapse prevention in ANCA vasculitis (PMID: 20488947)

Dosing

Target dose: 2–3 g/day in divided doses (BID)
Titration: Start at 500 mg BID; increase by 500 mg/week as tolerated to target
Mycophenolate sodium (Myfortic): Enteric-coated formulation; 720 mg Myfortic ~ 1000 mg MMF
Renal dosing: No formal renal adjustment, but GI side effects may be more frequent in CKD

GI Side Effects and Management

Diarrhea, nausea, and abdominal pain are the most common dose-limiting effects (up to 30–45% of patients)
Strategies: split into TID dosing; switch to Myfortic (enteric-coated); take with food; temporary dose reduction
Rule out CMV colitis or C. difficile if new diarrhea develops on immunosuppression

Therapeutic Drug Monitoring (TDM)

Mycophenolic acid (MPA) AUC: Target AUC_0–12 of 30–60 mg·h/L for lupus nephritis
Trough level (C0): Target 1.5–3.0 μg/mL (less reliable than AUC but more practical)
TDM most useful when: subtherapeutic response despite adequate dose, drug interactions suspected, or significant renal impairment
Drug interactions: Antacids and cholestyramine reduce absorption; proton pump inhibitors may modestly reduce MPA levels

Teratogenicity: MMF is FDA pregnancy category X. Effective contraception is mandatory. Discontinue at least 6 weeks before planned conception. Switch to azathioprine if pregnancy is desired.

6. Calcineurin Inhibitors in Glomerular Disease

Voclosporin (AURORA Trial)

Parameter	Detail
Trial	AURORA 1 (Phase 3, 2021) — PMID: 33388209
Design	Voclosporin 23.7 mg BID + MMF + low-dose steroids vs. placebo + MMF + low-dose steroids
Primary Endpoint	Complete renal response at 52 weeks: 41% voclosporin vs. 23% placebo (p < 0.001)
Dosing	23.7 mg BID (fixed dose); no therapeutic drug monitoring required
Advantages	Fixed dosing; more predictable PK than cyclosporine/tacrolimus; faster remission
Monitoring	eGFR (hold if >20% decline); BP; potassium; glucose; lipids
FDA Approval	January 2021 for active lupus nephritis in combination with background immunosuppression

Tacrolimus in Membranous Nephropathy

Dosing: 0.05–0.1 mg/kg/day in divided doses; target trough 4–8 ng/mL
Efficacy: Achieves remission in 60–80% of MN patients; however, high relapse rate (40–50%) after discontinuation
Monitoring: Trough levels weekly until stable, then monthly; renal function (nephrotoxicity risk); potassium; glucose; magnesium
Duration: Typically 6–12 months; slow taper over 4–6 months to reduce relapse risk
Often used in combination with low-dose steroids

Cyclosporine in Podocytopathies (MCD/FSGS)

Dosing: 3–5 mg/kg/day in divided doses; target trough 100–175 ng/mL
FSGS: Used as second-line for steroid-resistant or steroid-dependent disease (KDIGO 2021)
MCD: Alternative to prolonged steroid courses in frequently relapsing disease
MENTOR Trial comparison: Rituximab was non-inferior to cyclosporine for induction of remission in MN, and superior for sustained remission at 24 months

CNI Drug Interactions

Critical Interactions — CYP3A4 and P-glycoprotein:

Azole antifungals (fluconazole, voriconazole, itraconazole): Dramatically increase CNI levels (2–5x); reduce CNI dose by 50–75% and monitor trough closely
Macrolides (erythromycin, clarithromycin): Increase CNI levels; use azithromycin instead (minimal interaction)
Diltiazem/verapamil: Increase CNI levels by 30–50%; may be used intentionally as "CNI-sparing" in transplant
Grapefruit juice: Increases cyclosporine absorption; avoid
Rifampin, phenytoin, carbamazepine: Potent CYP3A4 inducers; dramatically decrease CNI levels; avoid if possible

7. Complement Inhibitors

Eculizumab / Ravulizumab in aHUS

Agent	Dosing	Notes
Eculizumab	900 mg IV weekly x 4, then 1200 mg IV every 2 weeks	First-line for atypical HUS; start empirically when TTP excluded (ADAMTS13 >10%); dramatic improvement in renal recovery (PMID: 23514287)
Ravulizumab	Weight-based loading dose, then maintenance every 8 weeks	Long-acting C5 inhibitor; non-inferior to eculizumab with less frequent dosing; FDA-approved for aHUS (PMID: 31535831)

Mandatory pre-treatment: Meningococcal vaccination (MenACWY + MenB) at least 2 weeks before first dose; if urgent, vaccinate and provide ciprofloxacin prophylaxis until 2 weeks after vaccination
Duration: Lifelong in most genetic aHUS; trial of withdrawal may be considered in complement factor H antibody-mediated disease after antibody titers normalize
Monitoring: CH50 (should be near-zero on therapy); CBC, LDH, haptoglobin, schistocytes for TMA activity

Avacopan in ANCA Vasculitis (ADVOCATE Trial)

Parameter	Detail
Trial	ADVOCATE (Phase 3, 2021) — PMID: 33596356
Drug	Avacopan (oral C5a receptor inhibitor) 30 mg BID
Design	Avacopan vs. prednisone taper (both with rituximab or cyclophosphamide induction)
Remission at Week 26	72.3% avacopan vs. 70.1% prednisone (non-inferior)
Sustained Remission at Week 52	65.7% avacopan vs. 54.9% prednisone (superior; p = 0.007)
eGFR Recovery	Significantly better eGFR improvement with avacopan vs. prednisone
Steroid Sparing	Allows glucocorticoid-free or minimal-steroid induction regimen
Adverse Effects	Hepatotoxicity (monitor LFTs); fewer steroid-related side effects
FDA Approval	October 2021 as adjunctive treatment for ANCA vasculitis

Emerging Complement Therapeutics in GN

Iptacopan (oral factor B inhibitor): Under investigation for C3 glomerulopathy and IgA nephropathy
Narsoplimab (MASP-2 inhibitor): Targets the lectin pathway; investigated in IgA nephropathy
Pegcetacoplan (C3 inhibitor): Being studied in C3G

8. Bone Protection During Steroid Therapy

Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. Bone loss is most rapid in the first 3–6 months of therapy.

Intervention	Dose / Detail	Indication
Calcium supplementation	1000–1200 mg/day (diet + supplements)	All patients on prednisone ≥2.5 mg/day for ≥3 months
Vitamin D	800–1000 IU/day cholecalciferol (D3); target 25(OH)D ≥30 ng/mL	All patients on prednisone ≥2.5 mg/day for ≥3 months
Bisphosphonates	Alendronate 70 mg weekly or risedronate 35 mg weekly or zoledronic acid 5 mg IV annually	Prednisone ≥7.5 mg/day for ≥3 months; OR any dose if T-score ≤−1.5; OR prior fragility fracture. Caution: Avoid if eGFR <30–35 mL/min (risk of adynamic bone disease in CKD; bisphosphonates accumulate and may worsen low-turnover bone disease)
Denosumab	60 mg SC every 6 months	Alternative to bisphosphonates; does not require renal dose adjustment; preferred in CKD 4–5 if no evidence of adynamic bone. Caution: Must not discontinue abruptly (rebound bone loss and vertebral fractures)
DEXA scan	At baseline if anticipated ≥3 months of glucocorticoid therapy	Repeat at 1 year; use FRAX with glucocorticoid adjustment

ACR/KDIGO Caveat: In advanced CKD (stages 4–5), standard osteoporosis treatments may be inappropriate. Check PTH and bone-specific alkaline phosphatase to differentiate high-turnover (secondary hyperparathyroidism) from low-turnover (adynamic) bone disease before initiating bisphosphonates.

9. Infection Prophylaxis

Pneumocystis jirovecii (PCP) Prophylaxis

Agent	Dose	Notes
TMP-SMX (first-line)	1 DS tablet (160/800 mg) daily or 3 times per week	Continue for duration of immunosuppression + 1–3 months after; also provides coverage for Nocardia, Listeria, Toxoplasma
Dapsone (alternative)	100 mg daily	Check G6PD before starting; monitor methemoglobin levels
Atovaquone (alternative)	1500 mg daily with food	Most expensive; well-tolerated; use if sulfa-allergic and G6PD-deficient
Pentamidine inhaled (alternative)	300 mg monthly via nebulizer	Does not prevent extrapulmonary PCP; bronchospasm risk

Indications for PCP Prophylaxis

Prednisone ≥20 mg/day (or equivalent) for ≥4 weeks
Any patient receiving cyclophosphamide, rituximab, or combination immunosuppression
Triple immunosuppression (e.g., CNI + MMF + prednisone as in lupus nephritis)
KDIGO 2021 GN guideline: recommend PCP prophylaxis for all patients receiving intensive immunosuppression for GN

Hepatitis B Screening and Management

Mandatory screening before rituximab, cyclophosphamide, or high-dose steroids: HBsAg, anti-HBc (total), anti-HBs
HBsAg positive: Start antiviral prophylaxis (entecavir or tenofovir) before immunosuppression; continue for 12–18 months after last dose
HBsAg negative / anti-HBc positive (occult HBV): Monitor HBV DNA and ALT monthly; start antiviral if DNA becomes detectable. Pre-emptive antiviral recommended if receiving rituximab (high reactivation risk)
Vaccinate: If anti-HBs negative and HBsAg negative, vaccinate before immunosuppression if possible

Vaccination Timing

Vaccine	Timing	Notes
Influenza (inactivated)	Annually; can give on immunosuppression	May have reduced efficacy; still recommended
Pneumococcal (PCV20 or PCV15 + PPSV23)	Before immunosuppression if possible	Per ACIP 2023 adult schedule
COVID-19 (mRNA)	Updated booster per current recommendations	Reduced antibody response on rituximab; time 4–6 months after last dose if possible
Hepatitis B	Before immunosuppression	If anti-HBs negative; high-dose series (40 mcg x 3) for CKD/dialysis
Meningococcal (MenACWY + MenB)	At least 2 weeks before eculizumab/ravulizumab	Mandatory for complement inhibitor therapy
Live vaccines (MMR, varicella, zoster live)	Contraindicated on immunosuppression	Give ≥4 weeks before starting IS; Shingrix (recombinant, non-live) IS safe

Practical Tip: Use the pre-immunosuppression window (often 2–4 weeks while awaiting biopsy results and insurance authorization) to administer vaccinations. Prioritize: pneumococcal, hepatitis B (if non-immune), and Shingrix (age ≥50).

Quick Reference: Immunosuppressive Agents Summary

Agent	Key Indications in GN	Major Toxicities	Essential Monitoring
Pulse Methylprednisolone	RPGN, severe LN, anti-GBM	Hyperglycemia, hypertension, psychosis, infection	Glucose Q6H, BP, infection signs
Oral Prednisone	Most GN as part of induction/maintenance	Osteoporosis, diabetes, AVN, cataracts, adrenal suppression	Glucose, DEXA, weight, BP, eye exam
Cyclophosphamide	ANCA vasculitis, severe LN, anti-GBM	Bone marrow suppression, hemorrhagic cystitis, infertility, malignancy	CBC at nadir (day 10–14), UA, fertility counseling
Rituximab	ANCA vasculitis, MN, relapsing MCD/FSGS, refractory LN	Infusion reactions, hypogammaglobulinemia, PML (rare), HBV reactivation	CD19/CD20, IgG levels, HBV serologies
MMF	Lupus nephritis (induction + maintenance), ANCA maintenance (second-line)	GI (diarrhea, nausea), bone marrow suppression, teratogenicity	CBC, LFTs, MPA levels (optional)
Voclosporin	Active lupus nephritis (FDA-approved)	Nephrotoxicity, hypertension, hyperkalemia, infections	eGFR, BP, K+, glucose
Tacrolimus	Membranous nephropathy, MCD/FSGS (steroid-dependent)	Nephrotoxicity, tremor, diabetes, hyperkalemia	Trough levels, SCr, K+, glucose, Mg2+
Eculizumab / Ravulizumab	Atypical HUS	Meningococcal infection (REMS), infusion reactions	CH50, LDH, haptoglobin, schistocytes, vaccination status
Avacopan	ANCA vasculitis (steroid-sparing adjunct)	Hepatotoxicity, infections	LFTs monthly x 6 months then quarterly

References

KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int. 2021;100(4S):S1-S276. PMID: 34556256
Stone JH, Merkel PA, Spiera R, et al. Rituximab versus cyclophosphamide for ANCA-associated vasculitis (RAVE). N Engl J Med. 2010;363(3):221-232. PMID: 20647199
Jones RB, Tervaert JW, Hauser T, et al. Rituximab versus cyclophosphamide in ANCA-associated renal vasculitis (RITUXVAS). N Engl J Med. 2010;363(3):211-220. PMID: 20647198
Guillevin L, Pagnoux C, Karras A, et al. Rituximab versus azathioprine for maintenance in ANCA-associated vasculitis (MAINRITSAN). N Engl J Med. 2014;371(19):1771-1780. PMID: 25372085
Jayne DRW, Bruchfeld AN, Harper L, et al. Randomized trial of C5a receptor inhibitor avacopan in ANCA-associated vasculitis (ADVOCATE). N Engl J Med. 2021;384(7):599-609. PMID: 33596356
Appel GB, Contreras G, Dooley MA, et al. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis (ALMS). J Am Soc Nephrol. 2009;20(5):1103-1112. PMID: 19369404
Dooley MA, Jayne D, Ginzler EM, et al. Mycophenolate versus azathioprine as maintenance therapy for lupus nephritis (ALMS maintenance). N Engl J Med. 2011;365(20):1886-1895. PMID: 22087680
Houssiau FA, Vasconcelos C, D'Cruz D, et al. Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial. Arthritis Rheum. 2002;46(8):2121-2131. PMID: 15846645
Rovin BH, Solomons N, Engelman W, et al. A randomized, controlled double-blind study of voclosporin for lupus nephritis (AURORA 1). Kidney Int. 2021;99(5):1141-1152. PMID: 33388209
Fervenza FC, Appel GB, Barbour SJ, et al. Rituximab or cyclosporine in the treatment of membranous nephropathy (MENTOR). N Engl J Med. 2019;381(1):36-46. PMID: 31269364
Legendre CM, Licht C, Muus P, et al. Terminal complement inhibitor eculizumab in atypical hemolytic-uremic syndrome. N Engl J Med. 2013;368(23):2169-2181. PMID: 23514287
Rondeau E, Scully M, Ariceta G, et al. The long-acting C5 inhibitor, ravulizumab, is effective and safe in adult patients with atypical hemolytic uremic syndrome naive to complement inhibitor treatment. Kidney Int. 2020;97(6):1287-1296. PMID: 31535831
Hiemstra TF, Walsh M, Mahr A, et al. Mycophenolate mofetil vs azathioprine for remission maintenance in ANCA-associated vasculitis (IMPROVE). JAMA. 2010;304(21):2381-2388. PMID: 20488947
ACR/EULAR 2019 Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol. 2019;71(9):1400-1412.
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Andrew Bland, MD, MBA, MS | University of Dubuque PA Program | urinenephrology.com