Brad Rovin, MD: Gaps in Treatment for Lupus Nephritis

Autoimmune diseases like lupus nephritis can be debilitating for patients.

During the American Society of Nephrology (ASN) Kidney Week in Washington, D.C., Brad Rovin, MD, department director of Nephrology at The Ohio State University Wexner Medical Center, explained in an interview with MD Magazine® some of the gaps in treatment of the disease and what is needed in the future to improve patient outcomes.

MD Magazine: What is needed for better outcomes for patients with lupus nephritis?

Rovin: The way I look at therapy for patients with lupus nephritis and autoimmune diseases and glomerular diseases in general, this is a very heterogeneous population.

Even though we histologically say a person, for example has class IV lupus nephritis, it's not only conceivable we have data suggesting that there's a lot of ways pathogenically to get to that pathway to get to that histology.

So, the pathways of injury are different and what I think we really needed in nephrology is an armamentarium of drugs that target specific pathways in a disease process.

Eventually what I want to be able to do and we'll talk about this more later this afternoon in some of the sessions here at the ASN is use the kidney biopsy and the patient's clinical parameters to understand what pathways are activated in an individual patient and then target the drug for that pathway.

So, we know that if we dissect the kidney biopsy that we do to make a diagnosis of lupus nephritis and look at the transcripts that are expressed, we find patients that have an interferon pathway activated, patients that have B-cell pathways activated, patients that have T-cell pathways activated.

So, you can see that coming down the road. If I have a drug like obinutuzumab available and I can analyze the patient as I make the diagnosis on a molecular level and that patient seem to have a very strong B-cell signal in their kidney my first choice could be this drug.

Why is that important? That's important because if I can use this drug and I'm being very theoretical here and not a lot of other things that have a lot of other side effects. I can treat the patients, hopefully get them into remission with a minimum of adverse events.

I guess I really should mention what was maybe surprising was even though with more B-cell depletion in the obinutuzumab, we found that the safety profile was as good. In other words, it was not adding risk to the patient in terms of adverse events.

I think that's the key when we start targeting very narrow specific pathways in patients with glomerular disease.

I think in the end we're going to see much more complete responses because we're hitting the pathway that's activated at that time in the patient. At the same time, we're doing it in a way where we're not killing the rest of the immune system and the patient can respond to infection. They don't develop bad side effects, so ultimately, I think that's what's needed nephrology.