What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?

Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.

I am a big believer in considering combination therapy as initial th...

It depends on the clinical context.

1. Was the patient completely off MMF and prednisone when they had the relapse.
2. How long after stopping the medications, they had relapse?
3. If they claim to be on MMF, then were they really taking it- would recommend getting levels, calling their pharmacy to get thei...

If they have been off of MMF and steroids for a while, then would resume therapy with MMF and steroids. The trick here would be to wean off immunosuppression slowly so it does not recur again and they will need higher dose of maintenance therapy once they achieve remission again.

If this is a relapse ON MMF, I question maintenance dose and I question compliance. If the dose is decent (2-3 g/d depending on patient size etc), I would consider adding rituximab. Once the patient is in remission, I might consider adding benlysta or voclo. The other question I always wonder is was...

Add Lupkynis.

Great answers above.

Would first rebiopsy!