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Proliferative lupus nephritis in sustained clinical renal response — SCE Rheumatology MCQ

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ModerateSystemic Lupus ErythematosusProliferative lupus nephritis in sustained clinical renal responseSCE Rheumatology

A 29-year-old woman with systemic lupus erythematosus developed biopsy-proven class IV-A lupus nephritis 30 months ago. She received glucocorticoids and mycophenolate mofetil, achieving complete clinical renal response after 6 months. This response has been maintained for the subsequent 24 months. She now takes mycophenolate mofetil 1 g twice daily and hydroxychloroquine 300 mg daily. Prednisolone was withdrawn 12 months ago. Her estimated glomerular filtration rate is 104 mL/min/1.73 m², urine protein:creatinine ratio is 18 mg/mmol and urine sediment is inactive. Complement levels and anti-double-stranded DNA antibody titre are normal. She has had no extrarenal flares, treatment toxicity or adherence concerns and is not planning pregnancy. She wishes to stop mycophenolate because of the tablet burden. Which management strategy is most appropriate?

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

Reveal the answer and explanation

Correct answer: D — Continue the current mycophenolate dose for 12 months, then reassess flare risk and consider repeat biopsy before tapering

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

She has maintained a complete clinical renal response, but has received only 24 months of immunosuppressive treatment following that response. Current EULAR lupus nephritis recommendations advise continuing immunosuppressive or biologic therapy for at least 3 years following renal response. Withdrawal may then be considered in sustained remission after assessing the individual risk of flare; repeat kidney biopsy should be considered when withdrawal is contemplated because clinical remission may not exclude persistent histological activity. Continuing mycophenolate for another 12 months before reassessment is therefore appropriate. A permits withdrawal before completing 3 years after response and omits reassessment. B is premature despite reassuring clinical and serological markers. C uses normal serology as the principal withdrawal criterion, although serological remission neither establishes histological remission nor supersedes the recommended treatment duration. D is attractive because repeat biopsy can inform withdrawal, but an inactive biopsy at this stage would not by itself justify shortening the recommended minimum period of post-response therapy. Hydroxychloroquine should ordinarily be continued regardless of any later decision to withdraw mycophenolate.

Reference: EULAR recommendations for the management of systemic lupus erythematosus with kidney involvement: 2025 update (16 October 2025) — https://www.eular.org/recommendations-management 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 with kidney involvement: 2025 update (Epub 16 October 2025; print January 2026) — https://pubmed.ncbi.nlm.nih.gov/41107121/