• Lupus Erythematosus, Systemic
• Lupus Nephritis
• Autoimmunity

We thank Dr Kronbichler et al for their interest in the recent update of the EULAR recommendations for systemic lupus erythematosus (SLE),1 and for bringing up an important aspect in the management of lupus nephritis (LN).2 The authors, who are all expert nephrologists, highlight the importance of adjunct treatment in LN beyond sole immunosuppression, with an emphasis on the potential use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). We fully align with the authors in their call for increased awareness regarding the management of chronic kidney disease (CKD) in LN, which should extend to patients with preserved estimated glomerular filtration rate (eGFR). It is becoming increasingly clear that a holistic care plan for all SLE patients with kidney involvement should have a dual targeting approach: immunosuppressive therapy to ameliorate inflammation and prevent consequences such as accrual of damage, together with long-term nephroprotective measures. For the latter, SGLT-2i have recently emerged as a promising treatment, based on their putative protective effects in the general population with CKD.3 4 Nevertheless, as the authors recognise in their correspondence, data on the use of SGLT2i in LN are still scarce. In particular, long-term data on hard outcomes and safety of coadministration of SGLT2i with immunosuppressive/biologic agents in SLE are needed to firmly establish their role in the management algorithm.

The issue raised by Kronbichler et al is whether a recommendation for SGLT2i use should be extended to all patients with LN and residual proteinuria (ie, urine protein >500 mg/24 hours), based on the recent labelling of patients with residual albuminuria as having ‘CKD’. The panel of experts addressed this in the 2023 EULAR recommendations for the treatment of SLE and has included the following phrasing in the manuscript: ‘Until more data are available, SGLT-2 inhibitors may be considered in patients with LN with reduced GFR below 60–90 mL/min or proteinuria more than 0.5–1 g/day, on top of ACE/ARBi during the maintenance phase’ (text accompanying statement nr. 13). In the respective figure of the recommendations’ manuscript (figure 2), it is written, for the sake of brevity, that these drugs ‘should be considered if decreased eGFR’. We thus agree with the authors that, pending more data regarding SGLT2i use specifically in LN, this decision should be individualised and based on ‘shared decision-making’.