A 32-year-old woman with SLE has serum creatinine 2.1 mg/dL, proteinuria 3.8 g/day, and urine RBC casts. Renal biopsy shows WHO class IV lupus nephritis. Which treatment regimen is now preferred as induction therapy per 2019 EULAR recommendations for class IV lupus nephritis?
- A High-dose cyclophosphamide (NIH protocol) + steroids
- B Azathioprine + steroids
- C Mycophenolate mofetil (MMF) + steroids ✓
- D Rituximab monotherapy
Correct answer: C. Mycophenolate mofetil (MMF) + steroids
Explanation
The 2019 EULAR/ERA-EDTA recommendations for lupus nephritis favour mycophenolate mofetil (2–3 g/day) plus glucocorticoids as a preferred induction regimen for class III/IV lupus nephritis, equivalent to low-dose cyclophosphamide (Euro-Lupus protocol) and superior in tolerability, particularly regarding gonadotoxicity. The landmark ALMS trial confirmed MMF non-inferiority to cyclophosphamide for induction. Azathioprine is used for maintenance, not induction.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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