Two-Hour Post-dose (C2)-Monitored Cyclosporine Microemulsion as a Practical Alternative to Voclosporin in Mixed Class IV/V Lupus Nephritis: A Case Report

Lupus nephritis (LN) is a major cause of chronic kidney disease and progression to end-stage kidney disease in patients with systemic lupus erythematosus. Calcineurin inhibitor-based therapy is used in LN management because of its combined systemic immunomodulatory effects on T-cell activation and direct podocyte-stabilizing actions, leading to reduction in proteinuria. We report a patient with mixed class IV and V LN who achieved partial remission with voclosporin but was unable to continue therapy. Transition to cyclosporine microemulsion (CsA-ME) guided by two-hour post-dose (C2) monitoring was associated with complete proteinuric remission and stable kidney function during follow-up. This case demonstrates that individualized C2-guided CsA-ME dosing was associated with marked proteinuria reduction and preservation of kidney function. The observed response suggests pharmacodynamic effects that may overlap with those reported for voclosporin, within a fully oral, non-depletive regimen selected to mitigate treatment-related toxicity from cytotoxic therapy after shared decision-making with the patient.