A 35-year-old woman with SLE (anti-dsDNA positive, low complement) presents with serum creatinine 2.4 mg/dL and 3+ proteinuria. Renal biopsy shows diffuse proliferative glomerulonephritis. According to EULAR/ERA-EDTA 2019 guidelines, what is the recommended induction immunosuppression?
- A High-dose cyclophosphamide (NIH regimen) alone
- B Mycophenolate mofetil 3g/day OR low-dose cyclophosphamide (Euro-Lupus regimen) with steroids ✓
- C Azathioprine 2mg/kg/day as first-line induction
- D Belimumab monotherapy for class IV lupus nephritis
Correct answer: B. Mycophenolate mofetil 3g/day OR low-dose cyclophosphamide (Euro-Lupus regimen) with steroids
Explanation
For class IV (diffuse proliferative) lupus nephritis, EULAR 2019 guidelines recommend MMF 2–3 g/day or low-dose cyclophosphamide (Euro-Lupus regimen: 500 mg IV q2 weeks x6 doses) as equivalent induction options combined with glucocorticoids. MMF is preferred in non-Caucasian patients. High-dose NIH cyclophosphamide has more toxicity without superior efficacy. Azathioprine is used for maintenance only; belimumab (BLISS-LN trial) is an add-on, not monotherapy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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