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Class V Lupus Nephritis Prognosis — RACP Adult Medicine MCQ

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ModerateNephrologyClass V Lupus Nephritis PrognosisRACP Adult Medicine

A 38-year-old woman with known SLE on hydroxychloroquine and mycophenolate develops new-onset proteinuria (4 g/day). Renal biopsy shows class V membranous lupus nephritis (pure membranous pattern). Anti-dsDNA is mildly elevated and complements are slightly low. What is the prognosis of class V lupus nephritis compared to class IV?

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Correct answer: E — Class V never requires treatment

Pure class V (membranous) lupus nephritis has a generally better prognosis than class IV (diffuse proliferative), with slower progression to ESKD. However, significant proteinuria (>3.5 g/day nephrotic range) warrants treatment. Immunosuppression is indicated if proteinuria remains nephrotic-range after 3–6 months of supportive therapy (ACEi/ARB). Treatment options include MMF, calcineurin inhibitors (tacrolimus – AURORA2 trial with voclosporin), or rituximab. Mixed class V+IV (V/III or V/IV) is treated as proliferative disease with a more aggressive approach.

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