Does the lupus nephritis classification provide information on treatment pathogenesis and prognosis?
The RPS/ISN classification provides valuable information on how to treat patients with lupus nephritis. Treatment of severe lupus requires aggressive immunomodulatory therapy.
Severe lupus encompasses classes III, IV, and V (if it has concomitant features of III and IV). Pure mesangial (II) or pure membranous (V) lupus typically require less aggressive immunomodulatory therapy.
Class III and class IV disease are further subdivided based on the inflammatory activity or chronicity of the lesions on kidney biopsy. The World Health Organization (WHO) classification was commonly used prior to the RPS/ISN classification. The advantage of the WHO classification is that it categorized information about the pathogenesis of the lesions (i.e., immune complex–mediated or non-immune complex–mediated).
The WHO classification also helps delineate prognosis, because patients with severe lupus nephritis have a worse prognosis than those with less severe disease.
In addition, those with diffuse proliferative lesions are generally more likely to achieve a remission and less likely to progress to end-stage kidney failure than those with severe segmental lesions, but both have a much higher risk of progression compared with mesangial or pure membranous disease.
