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Lupus nephritis (LN) is one of the most serious complications of SLE, manifesting as haematuria and/or proteinuria, hypertension and ultimately kidney failure. Despite advances in immunomodulatory treatments, outcomes have not significantly improved after 2000, with kidney failure still occurring in 10–30% of patients within 10 years of LN diagnosis. Impaired kidney function at LN onset predicts poor long-term renal and patient survival. Conversely, normalisation of renal function and urinalysis after treatment (‘renal response’) has been shown to correlate with favourable renal outcomes. However, recent randomised controlled trials (RCTs) have excluded patients with compromised kidney function, and few studies have focused on this LN subgroup. In the Aspreva subanalysis of 32 patients with severely impaired kidney function (estimated glomerular filtration rate (eGFR) <30 mL/min), only 16% of those receiving cyclophosphamide (CYC) and 20% of those receiving mycophenolate mofetil (MMF) achieved a renal response after 24 weeks. There were no significant differences in the clinical characteristics between the two groups at onset. Scarring at kidney biopsy was present in 42% of patients in the CYC and in 35% of the MMF group.1 This suggests that the current standard of care is insufficient for these patients, highlighting the need for more effective or combination therapies.