Systemic lupus erythematosus (SLE) is associated with a broad spectrum of clinical and immunologic manifestations, of which
lupus nephritis is the most common cause of morbidity and mortality. The development of
nephritis in patients with SLE involves multiple pathogenic pathways including aberrant apoptosis,
autoantibody production,
immune complex deposition and complement activation. The 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification system for
lupus nephritis was widely accepted with high intraobserver and interobserver concordance to guide therapeutic strategy and provide prognostic information. However, this classification system is not based on the underlying disease pathophysiology. Some additional lesions that contribute to disease presentation, including glomerular crescents, podocyte injury, tubulointerstitial lesions and
vascular injury, should be recognized. Although outcomes for patients with
lupus nephritis have improved over the past 30 years, treatment of this disease remains challenging and is best approached on the basis of the underlying pathogenesis, which is only partially represented by the various pathological phenotypes defined by the ISN/RPS classification. Here, we discuss the heterogeneous mechanisms involved in the pathogenesis of
lupus nephritis and how improved understanding of underlying disease mechanisms might help guide therapeutic strategies.