Phenotypic shift from active class IV lupus nephritis to lupus podocytopathy: a case report highlighting the treatment-altering role of repeat kidney biopsy.

Authors

Zhifa Wang, Jinxiu Deng, Jinfeng Shen, Hui Jiang, Fuzhen Wang

Published in

Frontiers in immunology. Volume 17. Pages 1941706. Epub Oct 06, 2026.

Abstract

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.
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.
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.

PMID:
42903163
Bibliographic data and abstract were imported from PubMed on 22 Oct 2026.

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