Lupus Nephritis Clinical Trials, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Caus

Описание: Four hospitalized patients with active lupus nephritis on various therapies present diverse clinical profiles-ranging from fluctuating kidney function and proteinuria to hypertension complications and infection risks. What clinical features and lab findings should inform your treatment strategy? How do randomized trial entry criteria influence therapeutic selections in these complex inpatients?

VIDEO INFO
Category: Lupus Nephritis Clinical Trials, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Causes, Diagnosis, and Management, Nephrology: Kidney Disease Diagnosis and Management
Difficulty: Expert - Expert level - For those seeking deep understanding
Question Type: Management - Clinical management decisions
Case Type: Multi Patient

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QUESTION
Four inpatients with active systemic lupus erythematosus kidney disease are discussed on morning rounds in a US tertiary ward. The unit has ready access to mycophenolate mofetil (MMF), belimumab infusion, and voclosporin; obinutuzumab requires pharmacy pre-approval and negative infection screening....

OPTIONS
A. Start voclosporin 23.7 mg twice daily with MMF titrated to 2 g/day and a rapid oral prednisone minimization ( =10 mg/day by weeks 10-12) in the 80-year-old with class IV-S, UPCR 2.1 g/g, eGFR 76 mL/min/1.73 m2, controlled blood pressure, and no active infection.
B. Add belimumab IV 10 mg/kg at weeks 0, 2, and 4 then every 4 weeks for the patient with isolated class V, UPCR 0.8 g/g, and eGFR 92 mL/min/1.73 m2.
C. Administer obinutuzumab 1000 mg on day 1, week 2, week 24, and week 26 with background azathioprine in the patient with shingles and absolute lymphocyte count 500/muL to achieve deep B-cell depletion before resuming MMF or altering steroids.
D. Start tacrolimus 0.1 mg/kg/day divided with MMF 1 g/day and maintain prednisone 20 mg/day for 24 weeks in the patient with class IV-G, UPCR 3.7 g/g, eGFR 34 mL/min/1.73 m2, and frequent hyperkalemia on ACE inhibitor therapy.

CORRECT ANSWER
A. Start voclosporin 23.7 mg twice daily with MMF titrated to 2 g/day and a rapid oral prednisone minimization ( =10 mg/day by weeks 10-12) in the 80-year-old with class IV-S, UPCR 2.1 g/g, eGFR 76 mL/min/1.73 m2, controlled blood pressure, and no active infection.

EXPLANATION
Voclosporin-based triple therapy most closely mirrors AURORA-1 entry criteria and the steroid-minimization paradigm when baseline eGFR is above 45 mL/min/1.73 m2, proteinuria is at least 1.5 g/g for class III/IV, blood pressure and potassium are reasonably controlled, and there is no active infection. Patient A has class IV-S (A) with UPCR 2.1 g/g, eGFR 76, controlled blood pressure on ACEi/CCB, and no infection-an excellent fit for initiating a calcineurin inhibitor add-on with rapid prednisone minimization per KDIGO 2024 and ACR 2025.

The remaining options misalign with trials or safety. Belimumab add-on for Patient B (pure class V, UPCR 0.8 g/g) does not reflect BLISS-LN populations (predominantly class III/IV +/- V and higher proteinuria); she also lacks a clear indication for escalation. Obinutuzumab for Patient C is inappropriate because of active varicella-zoster infection and lymphopenia, which are exclusionary for intensified B-cell-depleting therapy....


Further reading:

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