*5.1.3 Refractory lupus nephritis*

Rituximab (RTX), although off-label, is not only indicated in patients refractory to conventional therapy or after great cumulative dose of CYCi, but also in patients of child bearing age [47, 73, 74]. Another B-cell targeting therapy which inhibits BlyS, Belimumab has recently been proven to be beneficial as add-on to the standard of care (SOC) therapy (mainly in the MMF subgroup) with primary efficacy renal response seen by week 24 and sustained through week 104 [75].

It is recommended not to discontinue immunosuppression too early as most renal flares occurs during this period. Treatment withrawal can be considered in patients with sustained complete remission for 3–5 years, with treatment deescalation prior to complete withrawal of therapy [47]. Close monitoring of patients and management of co-morbidities including blood pressure (BP) control, treatment of hyperlipidaemia with statins and proteinuria with RAAS blockers are important, while vaccination against influenza and *Streptococcus pneumoniae* are strongly recommended. Repeat renal biopsy may be considered to guide the duration of maintenance immunotherapy and may be required in patients with incomplete response or recurrent LN flares [47, 65].
