Therapeutic Plasma Exchange in a Pediatric Lupus-Associated Thrombotic Microangiopathy: Prolonged Treatment Guided by Serial Biomarker Response.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease involving multiple organs including kidney. Class IV lupus nephritis is the most severe form and sometimes complicated by thrombotic microangiopathy (TMA), leading to microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury (AKI). We report a 9-year-old female diagnosed with Class IV lupus nephritis complicated by TMA, severe AKI, and resistant hypertension. Therapeutic plasma exchange (TPE) was initiated as an adjunctive therapy due to clinical severity. A total of 15 TPE sessions were performed over 4 weeks. Serial monitoring showed improvement in hematologic parameters, renal function, and clinical status. At 8-month follow-up, the patient maintained clinical and renal remission without relapse. This case highlights the role of prolonged, response-guided TPE in severe lupus-associated TMA in resource-poor settings where complement-targeted therapies are not available.