P91 Effective treatment of lupus nephritis and vasculitic fibrinoid necrotic ulcer with belimumab as add-on therapy

Objective A 35-year-old Polish patient was diagnosed with SLE in 2005 when presented with polyarthritis, photosensitivity rash, oral ulcers, positive ANA, Smith, DNA-43, low complements, positive anticardiolipin, and Beta 2 glycoprotein. She was initially on HCQ 400mg and Azathioprine 150mg. Methotrexate 15 mg weekly was added 2 years later for worsening polyarthritis. Method In 2015, she had a severe flare of lupus with arthritis, pericarditis, widespread lymphadenopathy with ESR >100, low complements, and dsDNA >1000. She was treated with methylprednisolone and mycophenolate (MMF)2g. This was complicated by septic arthritis (S aureus) in the right ankle and CMV infection, which were treated with antibiotics and antiviral. SLEDAI was 16 in 2016, but she responded partially to 2 courses of Rituximab (total dose of 4 g). 2017, she developed class V lupus nephritis (urine PCR 207) (SLEDAI 10). MMF 2g was recommenced. She relapsed in 2020 with PCR-606, vasculitis, low complements and DNA-215. MMF was increased to 3g. A repeat renal biopsy in 2021 showed Class IV lupus nephritis (active 4/24 and Chronic 5/12) and Class V lesions with no suggestion of APLS driving the disease. She suffered premature ovarian failure, found by serial FSH monitoring. Leg ulcer biopsy showed fibrinoid necrosis. She was treated with Cyclophosphamide EUROLUPUS regime in 2021. She developed osteoporosis and sustained a left ankle fracture (T -2.6 in hip and spine). Result Belimumab was started in Sept 2021. In 2023, her complements normalised, PCR-10.9, DNA -11, and ESR-21. She developed AVN in her left hip, requiring a hip replacement. She is currently on Prednisolone 4mg, MMF 3g, HCQ 200mg along with monthly belimumab. Conclusion Lupus nephritis is often associated with significant morbidity and mortality, and clinical presentation can be asymptomatic. Therefore, monitoring at each visit is encouraged. Kidney biopsy remains indispensable in its diagnosis and repeat biopsy should be considered in cases of relapse. Belimumab is a useful adjunct to MMF with good efficacy, a greater reduction in antibody profile (complement, DNA), and a reliable safety profile in recent trials.