Refractory Proteinuria in a Patient with Lupus Nephritis

Case AnswerA 43-year-old woman with a 20-year history of SLE and a 13-year history of lupus nephritis was referred to our hospital for evaluation of worsening proteinuria. During the past 20 years, the patient had experienced multiple flares of SLE, including central nervous system lupus and biopsy-proven renal flares, and hence, had received several pulses of intravenous methylprednisolone and cyclophosphamide. Four years before presentation, kidney biopsy to investigate increased urinary protein excretion of 6 g/d demonstrated both active and chronic glomerular lesions of lupus nephritis, including mesangial proliferation; wire-loop lesions; and numerous deposits in the subendothelial, intramembranous, subepithelial, and mesangial areas. After another pulse therapy, mycophenolate mofetil 1000 mg was added to prednisolone 10–15 mg/d. Azathioprine therapy was attempted but discontinued due to pancytopenia. Tacrolimus was given for a short period but discontinued due to …