[48] Combining calcineurin inhibitors with corticosteroids as induction immunosuppression was associated with clinically acceptable response rates in Czech, Chinese and Japanese patients.[46, 49-51] Triple immunosuppression with corticosteroids, tacrolimus and MMF has been reported to result in a higher complete remission rate (65% versus 15%) compared with

corticosteroids and intravenous CYC in Chinese patients.[10] There is also preliminary data on the efficacy of mizoribine in Japanese patients, and that of leflunomide in Chinese patients, but detailed comparison with standard therapies is lacking.[52, 53] Although the reported incidence of hepatitis was ∼7%, the liver toxicity of leflunomide is a valid concern and needs to be carefully monitored.[53] In view of the p38 MAPK inhibitors clinical trials data from retrospective analysis which showed that

anti-malarial treatment was associated with reduced incidence of flares (including renal flares) and less dyslipidaemia, the ACR and EULAR guidelines recommend that all LN patients be treated with a background of hydroxychloroquine unless there is contraindication.[17, 18] There is little data on the impact of hydroxychloroquine treatment in Asian patients. Alisertib cell line The KDIGO guidelines recommend that patients with Class V LN, normal renal function, and non-nephrotic proteinuria be treated with anti-proteinuric and anti-hypertensive agents, and corticosteroids or immunosuppressive agents be considered only when there are severe extra-renal manifestations.[16] Both the ACR and EULAR recommend that patients with pure membranous LN and nephrotic range proteinuria be treated with corticosteroids plus MMF (2–3 g/day),[17, 18] based on subgroup analysis of ALMS data which showed similar response rates to MMF or intravenous CYC at 6 months.[54] Meta-analysis of 34 studies (which included 174 Asian patients and 332 non-Asian patients) and data from an NIH controlled trial both showed that prednisone alone was inferior to dual immunosuppression with prednisone and a cytotoxic agent

or a calcineurin inhibitor.[55, 56] Relapses were more common following discontinuation of cyclosporin A compared with CYC. The EULAR guidelines do not recommend the Euro-Lupus regimen since it has not been tested in class V LN.[17] Data from Janus kinase (JAK) Asian patients has demonstrated efficacy of combined immunosuppression with prednisolone and sequential CYC-AZA, AZA, tacrolimus, or MMF.[57, 58] Socio-economic factors have a significant impact on the management of lupus nephritis in Asia. Factors such as financial limitations, education level and compliance of patients, the organization of healthcare structure and delivery, and the infection risks imposed by environment and climate, which vary markedly between different parts of Asia, can be strong determinants on the access to evidence-based standard-of-care and treatment decisions.