A 28-year-old woman with SLE develops Class III lupus nephritis confirmed on renal biopsy. Per current EULAR/ACR 2019 guidelines, what is the preferred induction immunosuppression regimen?
- A Low-dose cyclophosphamide (Euro-Lupus protocol) or mycophenolate mofetil with steroids ✓
- B High-dose cyclophosphamide (NIH protocol) alone
- C Azathioprine plus hydroxychloroquine without steroids
- D Rituximab plus tacrolimus as first-line induction
Explanation
Per EULAR 2019 and ACR 2024 guidelines for Class III/IV lupus nephritis, induction therapy consists of either low-dose cyclophosphamide (Euro-Lupus regimen: 500 mg IV every 2 weeks × 6 doses) or mycophenolate mofetil (2–3 g/day), both combined with pulse methylprednisolone followed by tapering oral prednisolone. Euro-Lupus protocol has equivalent efficacy to high-dose NIH cyclophosphamide with less gonadal toxicity and infections. Rituximab plus voclosporin (AURORA trial) is emerging but not first-line. Azathioprine alone is reserved for maintenance after successful induction.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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