Abstract: FR-PO0916
A Case of Novel Combination Therapy for Refractory Lupus Nephritis
Session Information
- Glomerular Case Reports: Lupus, FSGS, Complement, and More
November 07, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- Gulden, Daniel P., San Antonio Uniformed Services Health Education Consortium, Joint Base San Antonio Fort Sam Houston, Texas, United States
- Calder, Madison B., The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
- Bansal, Shweta, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States
Introduction
Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE), affecting nearly 40% of patients. Treatment becomes increasingly difficult in refractory cases. We present a patient with refractory class IV LN who achieved remission with combined therapy using voclosporin and belimumab.
Case Description
A 20-year-old woman was diagnosed with SLE at age 10, presenting with extrarenal symptoms. She was treated with mycophenolate mofetil (MMF), hydroxychloroquine, and prednisone but required frequent steroids for persistent symptoms and serologic activity. She had an allergic reaction to rituximab and no response to 14 months of belimumab. At age 16, she developed class IV LN with proteinuria and normal creatinine, treated with the Euro-Lupus cyclophosphamide protocol, which led to transient improvement and disease control. A flare 1.5 years later featured abdominal pain, rising proteinuria, elevated creatinine, and was diagnosed as medium-vessel lupus vasculitis. She received six months of cyclophosphamide, with ocrelizumab later added due to poor response. While systemic symptoms improved, proteinuria, hypertension, and active serologies persisted. At 19, voclosporin was added to MMF and low-dose steroids. Four months later, she was hospitalized with acute renal failure and found to have active LN with AIN on biopsy. Due to ongoing flares, nephrotic-range proteinuria, and refractory serologies, belimumab infusions were added to voclosporin, MMF, and a steroid taper. Over 12 months, she showed clinical improvement with normal serum albumin and complements, decreased proteinuria. By 15 months, she had the first time ever normalization of dsDNA, stable creatinine and proteinuria. At 20 months, she remains in remission.
Discussion
In patients with LN who have suboptimal response to MMF/cyclophosphamide and prednisone, current literature recommends addition of voclosporin if high proteinuria or belimumab if prior flares. Use of voclosporin reduces proteinuria but not extra-renal symptoms or serological abnormalities (AURORA-1). Belimumab therapy is known to have good serological and extrarenal outcomes (BLISS-LN). Our patient did not respond to either therapies individually with MMF and steroid; however, the novel combination of both achieved both clinical and serological remission for the first time in her 10 years of complicated SLE and LN history.