Infection is a leading complication of immunosuppressive treatment and an important cause of mortality in Asian LN patients.[65] Management of patients would need to take into consideration infections that are prevalent or endemic in some Asian countries, such

as hepatitis selleck screening library B and tuberculosis, since prophylaxis or pre-emptive treatment may be indicated.[66, 67] The risk of infective complications influences the dose of immunosuppressive agents. The starting dose of prednisolone is usually in the range of 0.8–1 mg/kg body weight daily for the initial treatment of severe proliferative LN. The use of pulse methylprednisolone varies, but many would use intravenous pulse methylprednisolone at 0.5–1 g daily for three days in patients who show extensive crescents on renal biopsy or rapidly progressive renal impairment. Also there is variation on the rate of corticosteroid dose tapering. The target dose of MMF for induction therapy in severe LN is mostly in the range of 1.5–2 g/day, and a high tolerance to MMF is generally observed. The choice and duration of MMF treatment are often dependent on financial Epacadostat considerations, since MMF or mycophenolic acid sodium is either a self-financed item or second-line (to CYC) immunosuppressive agent in many Asian countries, although health insurance reimbursement is available in some countries with specified criteria. In this context, quality-of-life scores were higher

during MMF treatment compared with scores associated with CYC induction in patients who had experience with both treatments, while the treatment cost associated with MMF could be partially offset by savings from the reduced incidence of complications.[34, C-X-C chemokine receptor type 7 (CXCR-7) 68] Also, the data from a recent

report showed that in patients who had been treated with prednisolone and MMF as continuous induction-maintenance immunosuppression the risk of disease flare was lower when MMF was given for at least 24 months compared with shorter treatment durations[35] In general, treatment is guided by disease severity, which is informed by histological data indicating the class, severity, and reversibility of nephritis, and clinical data which include the change in proteinuria, renal function, serology and extra-renal lupus manifestations. A summary of the consensus recommendations by ALNN members is presented (Table 3). Initial (Induction) immunosuppression in the form of combination therapy with corticosteroids (e.g. prednisolone 0.8 mg/kg/day) and either MMF or CYC (Level 1b) Pulse corticosteroid (e.g. methylprednisolone 0.5 to 1.0 g/day for 3 days) advisable when renal biopsy shows crescentic involvement >10% or evidence of deteriorating renal function. (Level 5) Tapering of corticosteroids to begin after 2 weeks except in patients with no sign of improvement, aiming to reach <20 mg/day after 3 months and ≤7.5 mg/day after 6 months.