Background/Purpose: About a half of the patients with systemic lupus erythematosus (SLE) can present lupus nephritis (LN) throughout the course of their disease, representing one of the most severe manifestations of SLE. Patients with LN could develop end-stage kidney disease which carry an important burden of morbidity and mortality. In order to improve the quality of care of patients with LN, several medical associations have developed clinical practice guidelines (CPG) and recommendations. However, the quality of care of these patients might be impacted by the quality of the CPG. To evaluate the quality of LN CPG, we aimed to critically appraise and compare the LN CPG from the main international medical associations.

Methods: We included globally representative CPG published in the last ten years that focused on LN or SLE including recommendations for renal involvement. We used the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. It comprised of 23 items organized into 6 quality domains: 1) Scope and purpose; 2) Stakeholder involvement; 3) Rigor of development; 4) Clarity of presentation; 5) Applicability; and 6) Editorial independence. It also includes two final overall assessment items that requires to make overall judgements of the practice guideline while considering how the 23 items were rated. Two appraisers review each CPG and any supplementals. The average score for each item was considered to calculate the final scores by domain. The results are presented for each CPG. Guidelines scores were compared overall and by domain. Descriptive statistical analysis was performed. ANOVA test was employed to evaluate the differences between the six domains of the AGREE instrument. A p-value < 0.05 was considered statistically significant.

Results: We included six CPGs that evaluated SLE and/or LN, published between 2018 and 2025. The oldest CPG appraised was GLADEL (2018), and the newest was ACR (2025). Four CPGs were developed by rheumatology associations (GLADEL, EULAR, APLAR, ACR), one by a nephrology association (KDIGO), and one was a collaboration of both rheumatology and nephrology (EULAR/ERA). Most CPGs involved both rheumatologists and nephrologists, except for KDIGO (only nephrologists) and GLADEL (only rheumatologists). Four out of the six CPGs took into consideration the patient’s preferences in the making of their recommendations (EULAR, APLAR, GLADEL, ACR). The CPG with the highest final score was KDIGO (6.3/7 points), and the lowest was APLAR (5.2/7 points). The domain with the lowest score across all CPGs was domain five (Applicability), with a mean of 4/7 points. On the contrary, domain four (Clarity of Presentation) was the highest graded (6.8/7 points) (Figure 1). When comparing scores of each domain between the six CPGs, only the domain 3 (Rigor of development) showed a significant difference (F= 5.120, p= 0.005) (Table 1).

Conclusion: The findings highlight areas for improvement in guideline development, particularly in making recommendations more applicable to diverse patient populations.

Numbers represents mean (SD).

Figure 1. Overall judgement and final scores of AGREE II instrument across six clinical practice guidelines for LN.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/lupus-nephritis-clinical-practice-guidelines-critical-appraisal-and-quality-comparison-using-the-agree-ii-tool/