Niranjan Ganesh

MBBS (Madurai MC),
MD (RIMS Imphal),
DM NEPHROLOGY (NIMS Hyderabad),
Consultant Nephrologist and Transplant Physician

[Dr.Mukesh , MD , DM @dr_immuno29]

Lupus Nephritis: The era of TRIPLE THERAPY is here.

For decades, induction therapy largely meant:

Glucocorticoid + MMF

The paradigm is changing.

The 2024 ACR guideline conditionally recommends upfront triple immunosuppressive therapy for active Class III/IV ± V lupus nephritis:

💊 Glucocorticoid
➕ MPAA/MMF
➕ ONE of:

🔹 Belimumab
🔹 Calcineurin inhibitor (CNI)
🔹 Low-dose IV cyclophosphamide + belimumab

📊 What does the evidence show?

BLISS-LN | Belimumab

At 104 weeks:

• Primary renal response: 43% vs 32%
• Complete renal response: 30% vs 20%
• Renal-related event/death: HR 0.51

→ Belimumab added to standard therapy improved renal outcomes.

AURORA-1 | Voclosporin

At 52 weeks:

• Complete renal response: 41% vs 23%
• OR 2.65
• Serious adverse events: 21% vs 21%

→ A CNI + MMF + low-dose steroids produced a rapid and significant renal response.

REGENCY | Obinutuzumab

Another important development:

• Complete renal response at week 76: 46.4%

→ B-cell depletion is expanding the therapeutic landscape of LN.

🎯 But “triple therapy” does NOT mean one regimen for everyone.

Proteinuria ≥3 g/g?
➡️ ACR favours MMF + CNI over belimumab-containing triple therapy.

Significant extra-renal disease?
➡️ A belimumab-containing regimen may be attractive.

eGFR ≤45 mL/min/1.73 m², severe hypertension or significant chronicity?
➡️ Belimumab preferred over CNI, given concerns about CNI nephrotoxicity/hypertension.

And an important caveat:

⚠️ There are still no head-to-head RCTs comparing the major triple regimens.

So the future isn’t simply:

“Triple therapy for everyone.”

It is:

“The right third drug for the right patient.”

From steroid + MMF
➡️ to phenotype-driven combination therapy
➡️ with an increasing focus on rapid proteinuria control + steroid minimisation + long-term kidney preservation.

Lupus nephritis treatment is becoming more precise.

#Rheumatology #Lupus #LupusNephritis #SLE #Nephrology #Immunology

[JAMA @JAMA_current]

#BrainDeath, or death as determined by neurologic criteria, can be difficult for families to understand because patients may still have a pulse, warm skin, chest rise with mechanical ventilation, or reflexive movements.

💡 This JAMA Insights article discusses how simple, direct, and precise language may help clinicians communicate that brain death is legal death and reduce confusion during evaluation and determination.

🔗 https://t.co/bbrewxFjpw

[CKJ @CKJsocial]

Treating depression in dialysis patients: pharmacological and non-pharmacological approaches

https://t.co/0Al7d9y9I8

[Critical Care Reviews @CritCareReviews]

Hypernatremia in the critically Ill: beyond free water replacement

CCR Journal Watch
https://t.co/Sp06oA6IDG

[Dr.Mukesh , MD , DM @dr_immuno29]

ANTIPHOSPHOLIPID SYNDROME | 2026 UPDATE

APS is no longer simply “aPL + thrombosis.”
Think phenotype + antibody profile + thrombotic risk.

🔹 CLASSIFICATION ≠ DIAGNOSIS
2023 ACR/EULAR criteria: ~99% specificity, ~74% sensitivity.
Obstetric APS: sensitivity only ~20–31%.
→ Don’t rule out APS by the score alone.

🔹 LOOK BEYOND THROMBOSIS
Microvascular disease • valve disease • thrombocytopenia • renal/neurological involvement = important APS phenotypes.

🔹 IDENTIFY HIGH-RISK APS
🚩 Lupus anticoagulant
🚩 Double/triple positivity
🚩 Arterial/microvascular disease
→ VKA remains the anchor.

🔹 DOACs? THINK TWICE.
❌ Avoid rivaroxaban in triple-positive APS.
For most thrombotic APS—particularly high-risk disease—VKA remains preferred.

🔹 RECURRENT THROMBOSIS?
Before intensifying therapy:
Adherence → INR/TTR → provoking factors → APS risk profile.
Then consider LDA / intensified VKA / LMWH in selected patients.

🔹 OBSTETRIC APS
LDA + heparin/LMWH remains the foundation.
Refractory disease → specialist-directed escalation; HCQ remains an emerging option.

🔹 HCQ: PROMISING, NOT PRACTICE-CHANGING—YET
2026 data suggest fewer recurrent thrombotic events, but evidence remains small & heterogeneous.

PRACTICAL TAKE-HOME

Suspect clinically → confirm persistent aPL → phenotype/risk-stratify → choose anticoagulation accordingly.

High-risk APS? → VKA.
Triple-positive? → Avoid rivaroxaban.
Recurrent event? → Investigate before simply escalating.
Obstetric APS? → LDA + heparin/LMWH.

The future: precision APS care—not one-size-fits-all anticoagulation.

#APS #Rheumatology #AntiphospholipidSyndrome #Medtwitter

References

Barbhaiya M, et al. Ann Rheum Dis. 2023;82:1258–1270.
Fujieda Y, et al. Curr Opin Immunol. 2026. doi:10.1016/j.coi.2026.102775.
Riancho-Zarrabeitia L, Riancho JA. Rheumatology. 2026. doi:10.1093/rheumatology/keag434.
de Carvalho JF, et al. Rheumatol Ther. 2026. doi:10.1007/s40744-026-00858-x.

[Updates in Medicine @medic_updates]

2026 definition of cardiogenic shock

[AJKD @AJKDonline]

Mitochondrial Alterations and CKD: A Review

https://t.co/0LOmShoigx (FREE)

@MeisterResearch @DenisPBlondin

[ILLIASUL IBAD @IlliasulK]

The FDA has approved brepocitinib (LISRAYA), the first oral therapy for adults with DM.

But what can we use in India until it becomes available?

1-Tofacitinib has the strongest off-label evidence, especially for refractory skin disease and anti-MDA5 DM-ILD

2-Upadacitinib has promising emerging data across skin, muscle and lung involvement

Practical alternatives, but not proven equivalents. Careful screening for TB, herpes zoster, CMV and other infections remains crucial. @docakx @IhabFathiSulima

[AJKD @AJKDonline]

Weight Loss-Independent Mechanisms of Kidney Protection with Glucagon-Like Peptide-1 Receptor Agonists and Implications for Clinical Practice

https://t.co/cBebcmxaqW

[soda_troubles, I have faith in Discord. @set_fortess]

Which patients should switch from rituximab to obinutuzumab in refractory nephrotic syndrome?
https://t.co/Ig56yfAQ84

[Alí Sebastian Meza @AliSMV7]

🔺Misdiagnosis of soft tissue infections: clinical pitfalls and management implications

https://t.co/xrv7LbXOjz

[EASO @EASOobesity]

Algorithm 2.0: EASO Pharmacological Framework for Obesity Management

✔️ Helps clinicians match pharmacological obesity management to an individual’s health needs, moving beyond weight loss alone to consider complications, mechanisms & treatment goals.

https://t.co/289FP5r93D

[NDT @NDTsocial]

Recommendations for pre-analytical urine sample handling to allow optimal assessment of albuminuria and proteinuria

https://t.co/NrxP0lKXaa

[Srinidhi @Srini41293]

Tropical infection related AKI

1/ Malaria - AKI - A thread

There are 5 species of Plasmodium

1. Plasmodium falciparum - The most severe and responsible for majority of Mortality and renal injury - INFECTS RBC'S OF ALL AGES

#NephPearls #AKI #Sri's pages #NEET

[NDT @NDTsocial]

Life support in hemodialysis emergencies—treatment standard

https://t.co/geIScvgHCZ

[CKJ @CKJsocial]

Integrating kidney imaging for risk prediction, therapeutic monitoring, and prognostication across the kidney disease spectrum: a review of emerging evidence

https://t.co/tLtDFMj9pK

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

Hypomagnesemia: Outpatient management
#Nephpearls

👉 https://t.co/5nbxKZovv3

[ASN Publications @asnpublications]

CKD nutrition is shifting toward plant-forward diets rich in fruits and vegetables while limiting ultra-processed foods. Greater use of dietitian-led medical nutrition therapy could improve outcomes. #CKD #KidneyHealth https://t.co/wbd6kwY593

[Abdul Muqtadir Abbasi @AbbasiMuqtadir]

Residents, fellows and physicians !!!!

You got a surgery planned and patient is on anticoagulation. Now stuck how to stop and restart anticoagulation.

Here is one chart you need for perioperative anticoagulation management.

#medtwitter #anticoagulation #surgery

[Edgar V. Lerma 🇵🇭 @edgarvlermamd]

B cell maturation, treatment targets, and therapies ca. 2026 from @Kidney_Int @goKDIGO
#Nephpearls

👉 https://t.co/geFcmXY3Je