Patient handout

Lupus Nephritis (ISN/RPS Classes I-VI)

PRODUCTION

1. Your condition

This handout is for lupus nephritis (isn/rps classes i-vi). Your care team identified this based on: new proteinuria (upcr >0.5 g/g) in sle patient (kdigo 2024 gn; eular/acr 2019).

Other reasons your team may use this plan: active urinary sediment (rbc casts, dysmorphic rbcs) in sle (kdigo 2024 gn); aki with low c3/c4 + positive ana/anti-dsdna → class iii/iv lupus nephritis suspected (kdigo 2024 gn); renal biopsy with isn/rps classification i-vi (kdigo 2024 gn; isn/rps 2003).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
hydroxychloroquine	5 mg/kg/day PO (max 400 mg/day)	PO	daily	KDIGO 2024 GN + EULAR/ACR 2019 — HCQ reduces flare + improves renal survival + lowers thrombosis + lipid benefit; annual ophthalmology screen for retinopathy after 5 years

Plan: Lupus nephritis class-stratified induction + maintenance (KDIGO 2024 GN; EULAR/ACR 2019 SLE; ALMS Appel JASN 2009; BLISS-LN Furie NEJM 2020; AURORA-1 Rovin Lancet 2021)

3. When to call your provider

Contact your care team if any of the following happen:

Rising UPCR or falling eGFR on induction → re-biopsy + escalate (belimumab / voclosporin / switch CY↔MMF) (KDIGO 2024 GN)
Active sediment + rising anti-dsDNA + falling complement → flare → admit if AKI (EULAR/ACR 2019)
New fever / leukopenia / hypoxia → ED with immunosuppressed alert (KDIGO 2024 GN)
New chest pain / hemoptysis / pulmonary-renal → ED + ICU triage (KDIGO 2024 GN)
CKD progression toward ESRD → transplant evaluation (KDIGO 2024 CKD)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

ISN/RPS Class III — focal proliferative LN; <50% glomeruli involved by endocapillary or extracapillary GN ± mesangial alterations (ISN/RPS 2003; KDIGO 2024 GN)
ISN/RPS Class IV — diffuse proliferative LN; ≥50% glomeruli involved (most severe class; aggressive induction mandatory) (ISN/RPS 2003; KDIGO 2024 GN)(life-threatening)
ISN/RPS Class V — pure membranous lupus; subepithelial immune deposits ± mesangial alterations; nephrotic presentation common (ISN/RPS 2003; KDIGO 2024 GN)
ISN/RPS Class VI — advanced sclerotic LN; ≥90% globally sclerotic glomeruli without residual activity (ISN/RPS 2003; KDIGO 2024 GN)
Mixed proliferative + membranous lupus — Class III+V or IV+V; combines proliferative and nephrotic phenotypes (ISN/RPS 2003; KDIGO 2024 GN)(life-threatening)
Nephrotic-range proteinuria ≥3.5 g/d in LN — guarded prognosis; CNI add-on (voclosporin AURORA-1) often indicated (KDIGO 2024 GN; Rovin Lancet 2021)
Refractory LN — persistent disease despite ≥2 induction agents (MMF + CY tried OR MMF + voclosporin/belimumab tried); consider rituximab + repeat biopsy (KDIGO 2024 GN; EULAR/ACR 2019)
Pregnancy in LN — MMF/CY teratogenic; switch to AZA + HCQ + low-dose steroid 3-6 months pre-conception; close maternal-fetal medicine + nephrology + rheumatology comanagement (EULAR/ACR 2019; KDIGO 2024 GN)
TMA-on-LN overlap — microangiopathic hemolytic anemia + thrombocytopenia + AKI on LN background (anti-phospholipid syndrome, atypical HUS, or LN-MAT); PLEX + immunosuppression escalation (EULAR/ACR 2019)(life-threatening)
Pulmonary-renal syndrome in LN — alveolar hemorrhage + AKI; route renal.rpgn.core.v1 for PLEX + ICU protocol (KDIGO 2024 GN; PEXIVAS 2020)(life-threatening)

5. Follow-up

Maintenance immunosuppression 3-5 years; CV-risk modification (statin, BP, glycemic); contraception/fertility planning; vaccination per ACIP 2026 (avoid live vaccines on immunosuppression); pregnancy planning post-remission (KDIGO 2024 GN; EULAR/ACR 2019)

6. Sources

Guideline: KDIGO 2021 Glomerular Diseases guideline (lupus nephritis chapter; KDIGO 2024 GN update pending) + EULAR/ACR 2019 SLE classification criteria + ALMS Appel JASN 2009 (MMF vs CY induction) + BLISS-LN Furie NEJM 2020 (belimumab adjunct) + AURORA-1 Rovin Lancet 2021 (voclosporin adjunct) + Euro-Lupus low-dose IV CY regimen