We would like to know your thoughts about the etiology of this patient’s hemoptysis and about our management of this patient thus far. The patient is an 18-year-old female who was diagnosed with lupus nephritis at the age of 16 (without a renal biopsy). She has been maintained at various times with solupred, cellcept, and/or hydroxychloroquine. Seven months after her initial diagnosis she developed lupus pneumonitis and required pulse-dose steroids. After approximately 9 months of therapy with one of the above medications, a renal biopsy was performed: class 4 lupus nephritis. At the time of the biopsy, she was placed on pulse –dose steroids again but developed convulsions. A brain MRI was consistent with lupus cerebritis. She was treated with a course of high-dose steroids, endoxan, ACE inhibitor, and other blood pressure medications. At this time, her serum creatinine ranged from 4.4 mg/dl to 5.1 mg/dl (BUN 43 to 54). Approximately one week later she presented with frank hemoptysis and hypertension (170/110 mm Hg). A chest CT scan revealed bilateral lung infiltrates (R > L). Labs revealed a hemoglobin of 6.5 g/dl, creatinine of 7.0 mg/dl, and platelet count 90,000. Hemodialysis along with additional pulse-dose steroids was administered. She remains dependent on renal replacement therapy and both steroids and endoxan.