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Lupus nephritis — SCE Rheumatology MCQ

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ModerateNephrologyLupus nephritisSCE Rheumatology

A 32-year-old woman with systemic lupus erythematosus has biopsy-proven class IV-G(A) and class V lupus nephritis. At presentation, her urine protein:creatinine ratio (uPCR) was 220 mg/mmol and estimated glomerular filtration rate was 64 mL/min/1.73 m². She received intravenous methylprednisolone followed by oral prednisolone, mycophenolate mofetil and belimumab. Hydroxychloroquine and renin–angiotensin system blockade were continued. Twelve months later, she is clinically well. Her uPCR is 62 mg/mmol, estimated glomerular filtration rate is 68 mL/min/1.73 m² and urinary sediment is inactive. Complement concentrations have normalised and anti-dsDNA antibody titres have fallen substantially. She is adherent to treatment, has had no significant toxicity and is taking prednisolone 2.5 mg daily. She does not intend to become pregnant. Which is the most appropriate next disease-modifying treatment plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Continue belimumab and mycophenolate mofetil, and withdraw prednisolone

Explanation lettering: E = shown as A · C = shown as B · A = shown as C · B = shown as E

Her uPCR of 62 mg/mmol is approximately 0.55 g/g, meeting the 12-month EULAR target of UPCR below 0.7 g/g, with preserved kidney function and inactive sediment. She has therefore achieved an appropriate renal response rather than treatment failure. Following response, the effective immune regimen should generally be continued for at least 3 years, based on the initial regimen. Prednisolone can be withdrawn because she is stable on steroid-sparing therapy and is already taking a minimal dose. A is a plausible de-escalation strategy, but stopping belimumab after only 12 months is premature when response was achieved using belimumab–mycophenolate combination therapy. B adds a calcineurin inhibitor despite satisfactory response; such intensification would increase treatment burden and toxicity without a current indication. D is unnecessary because mycophenolate is effective and tolerated. Azathioprine becomes preferable when mycophenolate is contraindicated, poorly tolerated or incompatible with pregnancy plans. E is inappropriate because rituximab is principally considered for refractory disease; falling proteinuria, inactive sediment and stable filtration do not indicate refractoriness. Thus, the established combination should continue while glucocorticoids are withdrawn.

Reference: EULAR recommendations for lupus nephritis (2025) — https://lupus.bmj.com/content/12/Suppl_1/A1.2 EULAR recommendations for the management of systemic lupus erythematosus: 2023 update (2023) — https://ard.bmj.com/content/83/1/15