A 32-year-old woman with SLE on hydroxychloroquine develops worsening proteinuria (3.2 g/day), haematuria, and serum creatinine rises to 2.1 mg/dL over 3 weeks. Renal biopsy shows diffuse endocapillary proliferative glomerulonephritis with subendothelial immune deposits. What is the initial induction regimen of choice?
- A Azathioprine plus oral prednisolone
- B Plasmapheresis plus cyclophosphamide
- C Mycophenolate mofetil 3 g/day plus pulse methylprednisolone followed by oral prednisolone ✓
- D Tacrolimus monotherapy
Explanation
This is lupus nephritis class IV (diffuse proliferative), the most severe class. Both mycophenolate mofetil (MMF) and cyclophosphamide are acceptable induction agents per EULAR/ACR guidelines; MMF at 2–3 g/day has replaced IV cyclophosphamide as the preferred induction agent in many centres because of equivalent efficacy and a better adverse effect profile (less ovarian toxicity, alopecia, and bladder toxicity). Pulse methylprednisolone 3 × 500–1000 mg followed by oral prednisolone 0.5–1 mg/kg/day is standard adjunct. Azathioprine is a maintenance (not induction) agent. Plasmapheresis has no proven role in pure class IV LN without TMA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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