A 30-year-old woman with SLE presents with painless gross hematuria, RBC casts, rising creatinine (1.8 mg/dL from baseline 0.9), and 24-hour protein of 2.9 g. Renal biopsy shows diffuse endocapillary and mesangial proliferation with 'wire-loop' lesions and subendothelial immune deposits on EM. Anti-dsDNA is 1:640 and C3/C4 are low. Per EULAR 2023 recommendations, what is the induction regimen?
- A High-dose prednisone + mycophenolate mofetil (Euro-Lupus or MMF-based induction) ✓
- B High-dose prednisone + azathioprine
- C High-dose prednisone + mycophenolate mofetil + belimumab (triple therapy)
- D Rituximab monotherapy
Explanation
This is Class III–IV lupus nephritis (diffuse proliferative, wire-loop lesions indicate heavy subendothelial deposits, typically Class IV). EULAR 2023 guidelines for Class III/IV LN recommend induction with high-dose glucocorticoids (IV methylprednisolone pulses + oral prednisone) combined with mycophenolate mofetil (2–3 g/day) as the preferred regimen over cyclophosphamide in non-life-threatening nephritis. Belimumab (anti-BLyS) added to standard of care has shown renal benefit in the BLISS-LN trial but is generally used in refractory or partial responders. Azathioprine alone is a maintenance agent.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.