A 30-year-old woman with known SLE on hydroxychloroquine presents with worsening proteinuria (2.8 g/day), haematuria, and hypertension. Renal biopsy shows mesangial and subendothelial immune deposits with 'wire-loop' lesions. What class of lupus nephritis does this represent and what is the initial treatment?
- A Class III (focal proliferative); treat with mycophenolate or low-dose cyclophosphamide
- B Class V (membranous); treat with ACE inhibitor alone
- C Class IV (diffuse proliferative); treat with high-dose corticosteroids plus mycophenolate or cyclophosphamide (Euro-Lupus or NIH protocol) ✓
- D Class II (mesangial); treat with hydroxychloroquine dose increase only
Correct answer: C. Class IV (diffuse proliferative); treat with high-dose corticosteroids plus mycophenolate or cyclophosphamide (Euro-Lupus or NIH protocol)
Explanation
Wire-loop lesions with subendothelial deposits and diffuse involvement characterise Class IV (diffuse proliferative) lupus nephritis — the most severe form. Standard induction is high-dose corticosteroids combined with either mycophenolate mofetil (preferred in Asian populations per ACR guidance) or cyclophosphamide (Euro-Lupus low-dose or NIH high-dose protocols). Class IV carries the worst prognosis without aggressive treatment.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.