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Refractory Lupus Nephritis — RACP Adult Medicine MCQ

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HardNephrologyRefractory Lupus NephritisRACP Adult Medicine

A 40-year-old woman with SLE on hydroxychloroquine and mycophenolate develops worsening proteinuria (6 g/day) despite treatment. Renal biopsy shows class V membranous lupus nephritis with positive PLA2R staining. What additional treatment should be considered?

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Correct answer: D — Add rituximab

Rituximab is increasingly used for refractory lupus nephritis, particularly class V (membranous) pattern. The positive PLA2R suggests a concurrent primary membranous nephropathy component. Rituximab depletes B cells and reduces autoantibody production. The LUNAR trial did not meet its primary endpoint, but subsequent data (including RING and other studies) support rituximab for refractory cases. Voclosporin (calcineurin inhibitor) added to MMF is another evidence-based option (AURORA trial).

Reference: eTG – 2025 – Rheumatology; KDIGO – 2024 – Lupus Nephritis Guidelines