How would you approach the management of a new SLE patient presenting with lupus podocytopathy with FSGS and severe proteinuria (Pr/Cr 18) without immune complex deposition?   

Hopefully one of the nephrologists will chime in on this one. However, this reminds me very much of a similar SLE patient I started to take care of about 6 years ago (BX = podocytopathy and FSGS; had marked proteinuria and renal dysfunction). I treated her with high-dose steroids, hydroxychloroquin...

I agree with Dr. @Thomas regarding the use here of a CNI because of their beneficial effects on podocytes and reversing foot process effacement. Additionally, I would minimize proteinuria, especially in the face of CKD, and consider one or more of the four pillars of proteinuria-reducing medications...