Lupus nephritis (LN) of juvenile onset often has severe disease presentation. Despite aggressive induction
therapy, up to 20% of patients with LN are resistant to initial
therapy and up to 44% suffer a renal relapse. However, there is no consensus on an appropriate therapeutic regimen for refractory LN. We report a 13-year-old girl with recurrent LN who was not taking her medications. At age of 11 years, she was diagnosed with LN classified as International Society of Nephrology/Renal Pathology Society (ISN/RPS) class IV G (A) + V. She was treated with
prednisolone and MMF after nine
methylprednisolone pulses. Nineteen months later, she was admitted to the hospital with generalized
edema. Her symptoms were
nephrotic syndrome and acute renal dysfunction. She received three
methylprednisolone pulses for 3 days, followed by oral
prednisolone and MMF. Twenty-seven days after the three
methylprednisolone pulses, her acute renal dysfunction was improved, but the
nephrotic syndrome was not improved. A second biopsy showed diffuse
lupus nephritis classified as the predominant finding of ISN/RPS class V. We added
tacrolimus to the MMF. Four months after adding
tacrolimus, the
nephrotic syndrome improved. We conclude that adding
tacrolimus to the treatment regimen for LN resistant to MMF is effective.