Multidisciplinary teams in lupus nephritis: where is the evidence for improved outcomes?

To the Editor,

Multidisciplinary team (MDT)-based care is now central to the management of systemic lupus erythematosus (SLE), particularly lupus nephritis (LN). Across the world, lupus care is increasingly delivered through collaborative models involving nephrologists, rheumatologists, renal pathologists, specialist nurses, pharmacists and obstetric physicians. This reflects the multisystem complexity of SLE and the need for coordinated long-term immunosuppressive and supportive care. International recommendations endorse multidisciplinary care as a core component of optimal SLE management.

However, despite widespread implementation, robust evidence that formal MDT structures improve hard clinical outcomes remains limited. A recent systematic review of multidisciplinary approaches in SLE concluded that, although MDT care is widely advocated and considered beneficial, the supporting evidence base is largely observational and focused on process measures rather than renal survival, organ damage or mortality [1].

This raises a key question: does formal MDT structure itself improve outcomes in LN, or has its implementation outpaced evidence?

In LN, the importance of early diagnosis and prompt immunosuppression is well established. Classical European cohort data demonstrated that diagnostic delay is strongly associated with adverse renal outcomes. In a Danish cohort, prolonged symptom duration prior to renal biopsy was independently associated with a significantly increased risk of progression to end-stage kidney disease [2]. Earlier Canadian studies similarly showed that delays in initiating immunosuppressive therapy are associated with worse renal outcomes and increased mortality, reinforcing the time-sensitive nature of LN management [3].

More recent UK qualitative data suggest increasing MDT integration; however, this has not translated into improved outcomes in SLE. A large UK-based cohort study of incident SLE between 2012 and 2023 demonstrated a >2-fold increase in mortality compared with matched controls, alongside persistently high rates of renal and multisystem complications [4]. This suggests that structural changes in care delivery, including MDT expansion, have not yet translated into clear improvements in long-term outcomes.

Evidence directly linking MDT care to improved LN outcomes remains sparse. A frequently cited LN MDT study reported reduced time to renal biopsy following implementation of a multidisciplinary model [5]. However, this was a before-and-after study across different time periods, introducing major potential for temporal confounding, including evolving biopsy thresholds and changes in immunosuppressive practice. Importantly, no clear reduction in time to treatment initiation or long-term renal outcomes was demonstrated.

We now have widespread MDT implementation, but there is still limited evidence that this improves outcomes in LN. Access to combined nephrology–rheumatology clinics, specialist nursing input, pharmacist led clinics and formalized lupus pathways differs between centres, suggesting that development has been driven mainly by service organization rather than outcome-based evidence.

In time-sensitive presentations such as active LN, additional procedural steps in organizing MDTs may also affect the speed of biopsy and treatment initiation, both of which are critical determinants of renal outcome.

This leaves an important gap in evidence regarding whether structured MDT processes improve outcomes or primarily represent an organizational framework for care delivery. Prospective evaluation of MDT models in LN is therefore needed to define their effect on treatment timeliness and renal outcomes.

CONFLICT OF INTEREST STATEMENT

None declared.