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Lupus nephritis — when SLE attacks the kidneys. Classes, symptoms, diagnosis, and modern induction-maintenance treatment.
Evidence reviewed & updated: 2026-08 — reflects the latest published trials and guidelines.
Lupus nephritis is kidney involvement in systemic lupus erythematosus — about half of lupus patients develop it, and it's the leading cause of lupus-related death. Early detection (urine + BP checks at every lupus visit) and modern induction-maintenance therapy have transformed outcomes from 'often fatal' to 'often manageable.'
About half of lupus patients develop kidney involvement, usually within the first years of disease. Risk is higher in women of African, Asian, and Hispanic ancestry, in younger onset, and with certain antibodies (anti-dsDNA, low complement).
Presentation ranges from silent proteinuria on a routine urine test to full nephrotic syndrome with edema and hypertension. Foamy urine, puffy eyes, and rising BP are the patient-level clues — but the UACR at every visit is what catches it early.
Kidney biopsy determines the ISN/RPS class: Class I-II (mild mesangial), Class III-IV (proliferative — the aggressive forms needing induction therapy), Class V (membranous), Class VI (advanced sclerosis). Class III/IV drive the standard treatment protocol.
Workup: UACR, eGFR, complement levels, anti-dsDNA, and biopsy when proteinuria or active sediment is present. Repeat monitoring after treatment uses the same markers.
Induction (first 6 months): high-dose steroids with either mycophenolate mofetil (MMF) or cyclophosphamide — both proven in trials; rituximab is used in resistant disease. Belimumab and voclosporin added to standard therapy improve renal response in clinical trials and are now part of the modern toolkit.
Maintenance (long-term): MMF or azathioprine plus hydroxychloroquine (which reduces flares and mortality — taken by all lupus patients without contraindication), ACEi/ARB and SGLT2i for proteinuria, and strict BP control. Relapse is common after stopping — maintenance continues for years.
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