Managing the kidneys in SLE
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In 2019, EULAR – The European Alliance of Associations for Rheumatology – published amended recommendations on the treatment of systemic lupus erythematosus (SLE) with kidney involvement. Since then, new evidence has become available, so the recommendations have been reviewed and updated again.

SLE is an autoimmune inflammatory disease. It can be very heterogeneous, causing different manifestations and symptoms, and affecting different organs and tissues in the body. The kidneys are affected in up to 60% of people with SLE – a condition referred to as lupus nephritis. This is linked to the development of chronic kidney disease (CKD) and potentially kidney failure. The knock-on effect is increased cardiovascular risk and higher mortality.

The general EULAR recommendations for SLE – last updated in 2023 – include some information about kidney disease,¹ but there was a need for additional, more specific interdisciplinary guidance.

The specific EULAR recommendations for people with SLE and kidney involvement were first published in 2012 and updated in 2019. New treatments have been developed since then, and new evidence has accumulated. To address this, EULAR decided that it was time to review and update these recommendations. Researchers, healthcare professionals, and patients worked together to develop new advice. Of note, the new, updated recommendations include a significantly smaller number of recommendations – down to 13 from 41 in the 2019 version. Some previous recommendations have been removed, some merged, and some are entirely new.

The new work, published in the October 2025 issue of the Annals of the Rheumatic Diseases, includes 4 overarching principles and 13 individual recommendations. The overarching principles emphasise that people with SLE should be monitored regularly for signs and symptoms of kidney involvement – with expert input and timely biopsies to ensure the best outcomes. Once kidney involvement has been diagnosed, management should align with the general recommendations for SLE, including use of hydroxychloroquine in all patients. Kidney involvement has a risk for CKD, and is best managed by an interdisciplinary care team including rheumatology and nephrology – and with shared decisions between the patient and their physician. Finally, management aims not only to prevent CKD progression, but also flares of nephritis, address comorbidities, and improve health-related quality of life. They stress that both immunosuppressive therapy and non-immune therapy are essential to ensure a favourable long-term prognosis.

The 13 new statements focus on the role of kidney biopsy, the recommendation for combination immunosuppressive treatment for most patients – including steroids, synthetic immunosuppressives, and biologics, as well as the importance of kidney protective drugs to reduce the risk for CKD. They also lay out specific guidance for patients with renal response versus those with persistently active or relapsing disease, and for women who may be seeking pregnancy.

“The updated EULAR recommendations highlight the two pillars of management for SLE patients with kidney involvement: combined immunosuppressive treatment to control the inflammatory process, and kidney protective measures – both lifestyle and pharmaceutical – to delay the occurrence or progression of CKD” said Antonis Fanouriakis – corresponding author on the paper and Assistant Professor or Rheumatology at Attikon University Hospital and the National Kapodistrian University of Athens in Greece. “With the cooperation of rheumatologists and nephrologists, and active patient participation in decision-making, it is hoped that prognosis of kidney involvement for patients with SLE will further improve in the near future.”

EULAR hopes the updated and streamlined recommendations will give physicians more evidence on which to base their therapeutic decisions for this challenging manifestation of lupus.

Source
Fanouriakis A, et al. EULAR recommendations for the management of systemic lupus
erythematosus with kidney involvement: 2025 update. Annals of the Rheumatic Diseases 2025; doi.org/10.1016/j.ard.2025.09.007

References
1. Fanouriakis A, et al.EULAR recommendations for the managementof systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024;83(1):15–29. doi:10.1136/ard-2023-224762.

About EULAR
EULAR is the European umbrella organisation representing scientific societies, health professional associations and organisations for people with rheumatic and musculoskeletal diseases (RMDs). EULAR aims to reduce the impact of RMDs on individuals and society, as well as improve RMD treatments, prevention, and rehabilitation. To this end, EULAR fosters excellence in rheumatology education and research, promotes the translation of research advances into daily care, and advocates for the recognition of the needs of those living with RMDs by EU institutions.

Contact
EULAR Communications, communications@eular.org