What factors do you consider when advising a patient with lupus nephritis on the safety of becoming pregnant?

I agree with Dr. @Dr. First Last's excellent suggestions (with just one exception!). I don't increase prednisone prophylactively for lupus pregnancy - I would only add or increase steroid if there is a flare. The risks of steroid in pregnancy impact both maternal and pregnancy outcomes, so we try to use them only when needed.

A couple of additional comments:

It is important to be confident that the patient is able to safely undergo pregnancy in terms of their current level of kidney function. If the eGFR is too low, the risk of ESKD as a result of pregnancy may be too high.

I agree with the need for quiet disease (remission or a low level of disease activity) 6 months before pregnancy. I would also want to be sure the patient has been adeq...

My approach, make sure you are in remission (tough to define, I agree) for at least 6 months.

• Get a high-risk OB.
• Take ASA for preeclampsia prophylaxis.
• Bump up your immunosuppression, perhaps add a bit of prednisone (15-20?).
• Get off MMF but change it to azathioprine.
• Consider a CNI if proteinuria gets worse.
• Obviously, stop RAASi.

The question doesn't say whether:

❓The patient has active lupus nephritis (LN) with continued proteinuria urine: protein creatinine ratio > 800 mg/mg (UPCR > 800), and her lupus nephritis drugs are still being altered in the attempt to control her disease

❓OR If the patient had recent lupus nephritis in the past several years, and is currently on maintenance therapy (e.g., mycophenolate plus a calcineurin inhibitor or belimumab plus hydroxychloroquine +/- steroids)

❓OR if the patient has a remote history of lupus nephritis, which is no longer active, and then the question is whether there is still residual proteinuria from permanent damage.

Each of these by itself would require a lengthy answer, and would be different for each.

I agree with...