A Case of Diffuse Lupus Nephritis Achieving Hemodialysis Withdrawal Following Seven Months of Sustained Immunosuppressive Treatment

Introduction: Lupus nephritis (LN), a severe manifestation of systemic lupus erythematosus (SLE), frequently progresses to end-stage renal disease. Even after the initiation of hemodialysis (HD), sustained immunosuppressive therapy may be necessary, particularly when renal biopsy reveals potentially reversible lesions. This case report describes a patient with LN who initially required HD due to anuria but later achieved renal recovery and was successfully weaned off dialysis following sustained immunosuppressive therapy. Case Description: A 49-year-old female presented with nephrotic-range proteinuria and weight gain one month prior to admission. Laboratory investigations showed a urinary protein-to-creatinine ratio of 6.7 g/gCr, hematuria (2+), elevated urinary N-acetyl-β-D-glucosaminidase (40.1 IU/L), serum creatinine 2.24 mg/dL, hemoglobin 8.0 g/dL, positive antinuclear antibody (1:320, fine-speckled), elevated anti-dsDNA antibody (939 IU/mL), and hypocomplementemia. Renal biopsy revealed diffuse proliferative LN (ISN/RPS Class IV), with endocapillary proliferation, cellular and fibrous crescents, and dense interstitial inflammation. Immunofluorescence showed a full-house pattern, and the modified NIH activity and chronicity scores were 15/24 and 3/12, respectively. Initial therapy with intravenous methylprednisolone pulses (1,000 mg/day for 3 days) followed by oral prednisolone (40 mg/day) did not improve renal function, leading to anuria and initiation of HD. Mycophenolate mofetil (500 mg/day) and tacrolimus (1 mg/day) were subsequently added to the treatment regimen. Despite a second steroid pulse, urine output remained absent, and prednisolone was tapered. However, gradual improvement in urine volume and renal function was noted, and the patient was successfully weaned from HD seven months after the initiation of immunosuppressive therapy. Discussion: The identification of active histopathological lesions with minimal chronic damage in LN patients can predict potential renal function recovery. Continuing immunosuppressive therapy after HD initiation may benefit select LN cases. Evaluating interstitial inflammation and chronicity on renal biopsy helps identify patients likely to regain function with intensive immunosuppression.