Dr Aruni Malaweera1, Dr Sukhpal Dayan2, Dr Rebecca Pellicano1, Dr Alberta Hoi3, Professor Richard Kitching1,4
1Department of Nephrology, Monash Health, 246 Clayton Road, Clayton, Australia, 2Department of Pathology, Monash Health, 246 Clayton Road, Clayton, Australia, 3Department of Rheumatology, Monash Health, 246 Clayton Road, Clayton, Australia, 4Centre for Inflammatory Diseases, Monash University Department of Medicine, 246 Clayton Road, Clayton, Australia
Background: The management of lupus nephritis (LN) is challenging; more than 50% of patients do not achieve a complete renal response (CRR) and up to 66% relapse despite treatment with standard immunosuppressive therapies. Belimumab (a recombinant human IgG1 monoclonal antibody that inhibits B lymphocyte stimulator) has been shown to be superior to placebo in achieving remission in patients with Class III, IV and V LN, but published experience assessing efficacy in patients with refractory LN is limited.
Case Report: Three patients included in the Australian Lupus Registry and Biobank received belimumab for refractory Class IV±V LN between June 2010-June 2021. These patients (two Asian males and one Caucasian female) had LN for 6-10 years prior to receiving belimumab and had failed to respond to mycophenolate mofetil, cyclophosphamide, tacrolimus and rituximab. Belimumab therapy improved proteinuria, renal function, serological markers of SLE and disease activity scores in the two male patients, permitting a reduction in prednisolone dosing. One patient had a repeat renal biopsy after 18 months of belimumab, which showed improved but persistent histological activity. The third case had significant glomerulosclerosis and chronic interstitial changes on renal biopsy at the time of the initiation of belimumab, and progressed to end stage renal failure despite belimumab therapy.
Conclusions: Belimumab provided therapeutic benefit in two of these refractory LN patients. Targeted efficacious therapies should be instituted early in the course of LN to achieve early remission of proteinuria and curtail the development of irreversible chronic renal damage. Further studies are needed to inform the effectiveness of belimumab for the long-term maintenance of remission, prevention of flares and monitoring of complications of B cell modulation.
Biography:
I am currently a third year advanced trainee in Nephrology at Eastern health. I completed my undergraduate medical degree at Cardiff university in the UK in 2011. After this, I completed my internship and medical training in London where I completed all three parts of the Membership of Royal College of Physicians Exams (MRCP). Once I came to Australia, I completed Basic Physicians training and one year of advanced training in general medicine after completing the Royal College of Physicians exams. I am hoping to a pursue a PhD next year