Phenotypic shift from active class IV lupus nephritis to lupus podocytopathy: a case report highlighting the treatment-altering role of repeat kidney biopsy
- 1Department of Nephrology, Longyan First Affiliated Hospital of Fujian Medical University
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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BibTeX
@article{wang2026phenotypic,
title = {{Phenotypic shift from active class IV lupus nephritis to lupus podocytopathy: a case report highlighting the treatment-altering role of repeat kidney biopsy}},
author = {Zhifa Wang and Jinxiu Deng and Jinfeng Shen and Hui Jiang and Fuzhen Wang},
journal = {Frontiers in Immunology},
year = {2026},
month = oct,
doi = {10.3389/fimmu.2026.1941706},
url = {https://www.frontiersin.org/articles/10.3389/fimmu.2026.1941706/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Phenotypic shift from active class IV lupus nephritis to lupus podocytopathy: a case report highlighting the treatment-altering role of repeat kidney biopsy
AU - Zhifa Wang
AU - Jinxiu Deng
AU - Jinfeng Shen
AU - Hui Jiang
AU - Fuzhen Wang
PY - 2026
DA - 2026/10/06
JO - Frontiers in Immunology
DO - 10.3389/fimmu.2026.1941706
UR - https://www.frontiersin.org/articles/10.3389/fimmu.2026.1941706/full
AB - 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.
SN - 1664-3224
ER -