A 28-year-old woman is diagnosed with lupus nephritis, World Health Organization (WHO)
type IV. She has a malar rash, diffuse arthritis, and edema. Her blood pressure is 190/110 mm
Hg. Her creatinine is 2.1 mg/dL with a blood urea nitrogen of 28 mg/dL. Her urine reveals 25 red
blood cells per hpf, and 3+ protein. One red blood cell cast is seen. A 24-hour urine collection
reveals a protein of 11 grams with a creatinine of 1 gram. Which of the following would be the
most appropriate management?
A. Oral azathioprine
B. Oral cyclophosphamide
C. Oral gold
D. Oral prednisone
E. Pulse IV cyclophosphamide
Explanation:
The correct answer is E. The most effective treatment for aggressive systemic lupus
erythematosus with nephritis is pulse cyclophosphamide. This has been shown to be the best
agent to treat type IV lupus nephritis.
Oral cyclophosphamide (choice B) is effective but not as effective as the pulse IV form.
Oral gold (choice C) is used to treat rheumatoid arthritis.
Oral prednisone (choice D) and oral azathioprine (choice A) are other commonly used agents but
are not as effective as cyclophosphamide.