What is the best next step in managing a patient with systemic lupus erythematosus (SLE), who presents with photosensitivity, malar rash, arthritis, positive Anti-double stranded Deoxyribonucleic acid (Anti-dsDNA) antibodies, evidence of lupus nephritis, and hypertension?

Management of SLE Patient with Lupus Nephritis and Hypertension

The best next step is to perform a renal biopsy (Option D) to determine the histologic class of lupus nephritis, which is essential for guiding appropriate immunosuppressive therapy and predicting prognosis. 1

Why Renal Biopsy Takes Priority

Renal biopsy has independent predictive ability for clinical outcome in lupus nephritis and must be interpreted in conjunction with urine sediment analysis, proteinuria, and kidney function. 1 This patient presents with "evidence of lupus nephritis" - but without knowing the histologic class (particularly whether this is Class III/IV proliferative disease versus other classes), you cannot select the optimal immunosuppressive regimen.

The Critical Decision Point

• Class III/IV proliferative lupus nephritis requires aggressive immunosuppression with glucocorticoids plus mycophenolic acid analogs, low-dose IV cyclophosphamide, or combination therapy with belimumab or calcineurin inhibitors. 1
• Without biopsy confirmation of the class, initiating potentially toxic immunosuppressive therapy would be premature and potentially harmful. 1
• Lupus nephritis leads to end-stage renal disease in 10% of cases at 10 years, making accurate classification and treatment critical for preventing irreversible kidney damage. 2, 3

Why the Other Options Are Inadequate

Option A (Reassurance) - Completely Inappropriate

• This patient has active major organ involvement (nephritis) with positive anti-dsDNA antibodies, which indicates high disease activity requiring immediate intervention. 4, 3
• Reassurance would lead to progressive kidney damage and potentially irreversible organ failure. 1

Option B (Start Corticosteroids) - Premature Without Biopsy

• While glucocorticoids are part of the treatment regimen for proliferative lupus nephritis, they should be combined with immunosuppressive agents based on the specific histologic class. 1
• Starting steroids alone before biopsy could mask disease activity and delay appropriate combination therapy. 1
• The 2024 KDIGO guidelines specifically recommend that patients with active Class III or IV lupus nephritis be treated with glucocorticoids PLUS one of several immunosuppressive options - not glucocorticoids alone. 1

Option C (Control Blood Pressure) - Important But Not the Priority

• Blood pressure control is indeed part of the general management strategy for lupus nephritis patients and helps with cardiovascular risk reduction and renoprotection. 1
• However, blood pressure at 155/90 mmHg, while elevated, is not a hypertensive emergency requiring immediate intervention before addressing the underlying active nephritis. 1
• Blood pressure optimization should occur concurrently with, not instead of, definitive diagnosis and treatment of the lupus nephritis. 1

The Proper Management Algorithm

Step 1: Obtain Renal Biopsy Immediately

• Perform renal biopsy to determine histologic class, degree of activity versus chronicity, and guide treatment selection. 1
• Evaluate urine sediment, quantify proteinuria, and assess kidney function alongside biopsy results. 1, 4

Step 2: Initiate Treatment Based on Biopsy Results

• For Class III/IV proliferative lupus nephritis: Start glucocorticoids plus mycophenolic acid analogs (first-line), OR low-dose IV cyclophosphamide, OR consider adding belimumab, OR use combination therapy with calcineurin inhibitors if eGFR >45 mL/min/1.73m². 1
• Consider reduced-dose glucocorticoid regimens following methylprednisolone pulses when both kidney and extrarenal manifestations show satisfactory improvement. 1

Step 3: Implement Adjunctive Therapies Concurrently

• Ensure hydroxychloroquine is prescribed (unless contraindicated), as it should be used in all SLE patients including those with lupus nephritis. 1, 4
• Initiate blood pressure control with RAAS blockade (ACE inhibitors or ARBs) for renoprotection in stable patients without acute kidney injury. 1
• Implement cardiovascular risk reduction measures including dyslipidemia management. 1
• Provide photoprotection counseling and broad-spectrum sunscreen for the photosensitivity and malar rash. 1, 4

Step 4: Address Infection Risk and Other Complications

• Screen for hepatitis B, hepatitis C, HIV, and tuberculosis before initiating immunosuppression. 1
• Consider Pneumocystis jirovecii prophylaxis depending on the immunosuppressive regimen selected. 1
• Assess bone mineral density and initiate calcium/vitamin D supplementation given anticipated glucocorticoid use. 1

Critical Pitfalls to Avoid

• Never start aggressive immunosuppression for presumed lupus nephritis without biopsy confirmation of the histologic class - treatment regimens differ significantly based on class. 1
• Do not delay biopsy to control blood pressure first - the BP elevation is likely secondary to the active nephritis and will improve with appropriate treatment of the underlying disease. 1
• Avoid using glucocorticoids as monotherapy for lupus nephritis - combination with immunosuppressive agents is essential for preventing progression to end-stage renal disease. 1
• Do not forget to ensure hydroxychloroquine is part of the regimen, as it reduces mortality and disease activity in all SLE patients. 1, 4, 3