Successful Bridging to Rituximab With Plasma Exchange in a Pediatric Patient With Severe Lupus Nephritis

We report a case of a 14-year-old girl diagnosed with class IV-G (A) lupus nephritis (LN), presenting with severe clinical manifestations, including nephrotic syndrome, acute kidney injury, and life-threatening hyperkalemia. The condition was managed with early initiation of plasma exchange (PE), followed by a combination of immunosuppressive therapies: high-dose corticosteroids, mycophenolate mofetil, rituximab, tacrolimus, and hydroxychloroquine. PE was promptly introduced after methylprednisolone pulse therapy to reduce circulating pathogenic autoantibodies and mitigate renal inflammation. Renal function gradually improved, accompanied by a marked decline in antibody levels. During recovery, the patient developed deep vein thrombosis and pulmonary embolism, which were managed with anticoagulation therapy. Belimumab was subsequently added to facilitate steroid tapering and maintain long-term disease control. Over an 18-month follow-up period, the patient achieved complete remission, with normalization of serologic markers and urinary findings, and corticosteroids were successfully discontinued. This case highlights the potential utility of early PE in enabling effective rituximab treatment for severe pediatric LN and underscores the importance of individualized, multimodal strategies to optimize outcomes in high-risk patients.