ArticleFrontiers in immunology2026
Phenotypic shift from active class IV lupus nephritis to lupus podocytopathy: a case report highlighting the treatment-altering role of repeat kidney biopsy.
Article in Frontiers in immunology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: The underlying pathophysiological mechanisms of proteinuria relapse in lupus nephritis (LN) patients during immunological remission are complex, often involving non-immune complex-mediated podocyte injury. Case presentation: We report a 21-year-old male with class IV LN and thrombotic microangiopathy (TMA). After multi-target induction and maintenance therapy, the patient achieved complete clinical remission. During subsequent follow-up, he developed progressive nephrotic-range proteinuria while maintaining serological remission (persistently negative autoantibodies and normal complement levels). Intensification of conventional immunosuppressants was ineffective. A repeat kidney biopsy revealed significant resolution of immune complex deposits but prominent focal segmental glomerulosclerosis (FSGS)-like changes with extensive podocyte foot process effacement. The regimen was adjusted to a podocyte-targeted therapy centered on tacrolimus, resulting in a rapid and sustained reduction in proteinuria. Conclusion: This case suggests that in the clinico-serological dissociation phase of LN, repeat kidney biopsy is of significant clinical value for identifying pathological phenotypic shifts, avoiding excessive immunosuppression, and guiding precision medicine.
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