Voclosporin for the treatment of lupus nephritis flares in patients with inadequate response to mycophenolate mofetil and belimumab: a case series

Lupus nephritis (LN) is a frequent and severe manifestation of systemic lupus erythematosus (SLE) associated with progression to kidney failure in up to 30% of cases, higher morbidity, and increased mortality. Recent advances in the management of LN have highlighted a shift toward a combination of immunosuppressive therapies, with agents such as belimumab and voclosporin expanding the treatment options. However, the optimal use and timing of these agents in relapsing disease remains to be established. Here, we describe three cases of LN flares with nephrotic-range proteinuria that were effectively treated with the third-generation calcineurin inhibitor, voclosporin. The first case describes a young woman who developed LN and, despite mycophenolate and belimumab combination treatment, also developed acute kidney injury and worsening proteinuria. Similarly, the second patient is a male who experienced a nephrotic flare following an infectious trigger and showed insufficient response to mycophenolate combined with belimumab. Finally, the third report describes a woman who developed an LN flare shortly after starting belimumab. In all three cases, voclosporin effectively controlled LN relapses, with treatment generally being well tolerated and no clinically relevant adverse events observed, highlighting its potential role in treating nephrotic LN flares, as suggested by the most recently published treatment guidelines.