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October 23, 2025Open Access

Predictors of a successful glucocorticoid tapering and withdrawal in an inception cohort of patients with lupus nephritis and associations with long-term outcomes and damage accrual

Key Points

Successful glucocorticoid tapering impacts long-term outcomes in patients with lupus nephritis after treatment.
Patients with lupus nephritis showed significant correlations between clinical characteristics and outcomes during tapering.
Analysis of clinical and histological characteristics provided insights into the predictors affecting glucocorticoid use.
Findings highlight the importance of hydroxychloroquine in managing lupus nephritis and preventing renal flares.

Abstract

Objectives The optimal duration of glucocorticoid (GC) treatment in lupus nephritis (LN) remains unclear. We examined predictors of GC tapering and discontinuation (D/C), flares during tapering and post-D/C and long-term outcomes. Methods We analysed inception cohort data (1992–2021) from 136 patients with LN (median follow-up: 121 months) and applied regression models to assess predictors of successful GC D/C and long-term outcomes, including clinical/laboratory, histological and treatment characteristics. Results Median time to 7.5 mg/day, 5 mg/day and GC D/C was 9, 12 and 29 months post-diagnosis, respectively. Composite complete renal response (CR) and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)-2K≤4, sustainedly attained until GC D/C (HR: 1.85, p=0.016), membranous LN (HR: 1.81, p=0.01) and persistent use of hydroxychloroquine (HR: 1.49, p=0.04) were associated with a shorter time to GC D/C. Patients diagnosed after 2010 achieved earlier GC D/C. Shorter time to CR (OR: 1.05, p=0.034) and Lupus Low Disease Activity State at tapering from 7.5 mg/day onwards (OR: 0.23, p=0.046) reduced flare risk during tapering. Definition Of Remission In Systemic Lupus Erythematosus (DORIS) complete remission at D/C (OR: 0.20, p=0.005) and persistent hydroxychloroquine use (OR: 0.28, p=0.031) protected against post-D/C renal flares. Neither higher initial GC dose (>40 mg/day) nor slower GC tapering prevented renal flares. Time to GC D/C (OR: 1.02/month, p=0.04) and flares (OR: 2.08, p=0.036) were associated with damage risk at the end of follow-up. Conclusion Sustained CR/SLEDAI-2K≤4, membranous LN and persistent hydroxychloroquine use emerged as main predictors of shorter time to D/C, while DORIS complete remission at D/C and persistent hydroxychloroquine use predicted post-DC flares. Time to GC D/C and flares independently contributed to 10-year damage accrual.

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