Unmet Needs in the Management of Adult Patients with Lupus Nephritis.

Lupus nephritis is a major cause of morbidity and long-term kidney damage in patients with systemic lupus erythematosus. Despite therapeutic advances, complete remission rates remain modest, and progress to kidney failure still occurs in a substantial proportion of patients. Contemporary management has shifted toward early initiation of 'triple therapy', yet patients continue to suffer from the adverse effects of prolonged glucocorticoid exposure. Challenges persist, including treatment duration, safe tapering, and the high rates of flare following immunosuppression withdrawal, underscoring the potential role of repeat kidney biopsy in guiding decisions. Poor adherence is very common and a significant impediment in daily practice and often leads to the incorrect classification of patients as having 'refractory disease'. Furthermore, conventional biomarkers are not ideal for flare prediction. Emerging therapies offer promising efficacy but remain inaccessible for many patients due to high costs and different reimbursement policies. Comprehensive management further requires attention to pregnancy planning, infection prophylaxis, care of chronic kidney disease, and long-term complications such as malignancy and osteoporosis. The goal should be to preserve kidney function, minimize cumulative toxicity, and restore quality of life to all patients, regardless of geography or economic status. This article provides a perspective of the Immunonephrology Working Group (IWG) of the European Renal Association (ERA) and discusses the key unmet needs in the management of lupus nephritis.