A 28-year-old woman with SLE on hydroxychloroquine develops worsening proteinuria (3.8 g/day), haematuria, and rising creatinine. Renal biopsy shows diffuse proliferative glomerulonephritis with 'wire-loop' lesions and subendothelial immune deposits. What is the current first-line induction therapy?

• A High-dose pulse methylprednisolone alone
• B Azathioprine + glucocorticoids
• C Mycophenolate mofetil + low-dose glucocorticoids ✓
• D Cyclophosphamide Euro-Lupus regimen alone

Explanation

Class III/IV lupus nephritis (diffuse proliferative pattern as in this case) is managed with mycophenolate mofetil (MMF, target 2–3 g/day) plus low-dose glucocorticoids as equivalent to, and better tolerated than, cyclophosphamide (ALMS trial). EULAR 2019 and ACR 2024 guidelines endorse MMF as preferred first-line induction in non-Hispanic, non-Black patients; cyclophosphamide Euro-Lupus protocol is an alternative. Belimumab or voclosporin can be added in refractory/high-risk disease. Azathioprine is maintenance, not induction therapy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.