A 35-year-old woman with SLE develops rising creatinine, proteinuria 2.4 g/day, and red cell casts. Renal biopsy shows diffuse proliferative nephritis. According to current EULAR/ERA-EDTA guidelines, what is the preferred induction regimen?
- A Low-dose cyclophosphamide (Euro-Lupus protocol) plus glucocorticoids plus hydroxychloroquine ✓
- B High-dose cyclophosphamide (NIH protocol: 0.75–1 g/m² monthly ×6) alone
- C Mycophenolate mofetil 3 g/day plus glucocorticoids with belimumab add-on
- D Rituximab monotherapy with deferred glucocorticoids
Correct answer: A. Low-dose cyclophosphamide (Euro-Lupus protocol) plus glucocorticoids plus hydroxychloroquine
Explanation
For lupus nephritis class III/IV, current EULAR 2019 guidelines recommend induction with either low-dose cyclophosphamide (Euro-Lupus: 500 mg IV every 2 weeks for 3 months) or mycophenolate mofetil 2–3 g/day, both combined with glucocorticoids. Hydroxychloroquine is recommended in all SLE patients without contraindication as background therapy. Euro-Lupus protocol has equivalent efficacy to high-dose NIH protocol with less toxicity. Belimumab add-on therapy is emerging evidence but not yet first-line induction in diffuse proliferative nephritis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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