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OBJECTIVES

OBJECTIVES. NOT TO BE A NEPHROLOGIST TO UNDERSTAND LUPUS NEPHRITIS AS A PRIMARY CARE PHYSICIAN. OBJECTIVES. Define nephrotic syndrome and glomerulonephritis Identify the Diagnostic criteria for SLE Antibodies markers in SLE Prognostic markers in SLE

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OBJECTIVES

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  1. OBJECTIVES • NOT TO BE A NEPHROLOGIST • TO UNDERSTAND LUPUS NEPHRITIS AS A PRIMARY CARE PHYSICIAN .

  2. OBJECTIVES • Define nephrotic syndrome and glomerulonephritis • Identify the Diagnostic criteria for SLE • Antibodies markers in SLE • Prognostic markers in SLE • Classification of lupus nephritis • Indications and contraindications of renal biopsy • Common side effects of medicine used in lupus nephritis

  3. FOCAL NEPHRITIC DIFFUSE NEPHRITIC URINALYSIS Similar to focal disease but heavy proteinuria (which may be in nephrotic range) Edema Hypertension + Renal Insufficiency • URINALYSIS • Red cells ( usually dysmorphic ) • Red cell cast • Mild proteinuria (<1.5gm /day) • Findings of more severe disease are usually absent

  4. Why Dr Reed’s Top Differential was Lupus ?

  5. Why did he order anti-dsDNA and anti-SM antibody? What is the role of complement level in lupus nephritis?

  6. Serologic test • ANA's are a highly sensitive screen for SLE, being found in more than 90% of untreated patients, but they are not specific for SLE. • anti-dsDNA are a more specific but less sensitive marker of SLE and are found in almost three fourths of untreated patients with active SLE(97% specificity). • Titers of anti-dsDNA antibodies often fluctuate with disease activity. • Anti-Sm antibodies, although very specific for SLE are found in only about 25% of lupus patients.

  7. MONITORING CLINICAL DISEASE • There is controversy regarding the value of a declining C3 and C4 level and a rising anti-DNA antibody titer in predicting a clinical flare of SLE or active renal disease.clearly these are the most widely used serologic tests to monitor SLE activity. • Nonspecific:ESR /CRP

  8. SO IF A PATIENT HAS POSITIVE SEROLOGIC MARKERS FOR LUPUS WHICH CORRELATE WITH CLINICAL FINDINGS DO THEY STILL NEED A RENAL BIOPSY ? AND WHY?

  9. CLASSIFICATION OF LUPUS NEPHRITIS • CLASS I (Minimal Mesangial lupus Nephritis) • CLASS II(Mesangial Proliferative Lupus Nephritis) • CLASS III(focal lupus nephritis) • CLASS IV (diffuse Lupus Nephritis ) • CLASS V (membranous lupus nephritis ) • CLASSVI (Advanced sclerosing lupus nephritis)

  10.   International Society of Nephrology/Renal Pathology Society (2003) Classification of Lupus Nephritis Class I Minimal mesangial LN Class II Mesangial proliferative LN Class III    Focal LN* (<50% of glomeruli)    III (A): Active lesions   III (A/C): Active and chronic lesions   III (C): Chronic lesions Class IV    Diffuse LN* (≥50% of glomeruli)    Diffuse segmental (IV-S) or global (IV-γ) LN   IV (A): Active lesions   IV (A/C): Active and chronic lesions   IV (C): Chronic lesions Class V[†] Membranous LN Class VI Advanced sclerosing LN (≥90% globally sclerosedglomeruli without residual activity) .

  11. Indications and contraindications of Renal Biopsy • INDICATIONS: • Persistent proteinuria (especially if >3.5gm/24hrs) not due to diabetes. • Persistent glomerularhematuria(especially if accompained by RBC cast) • Unexplained acute renal failure

  12. RENAL BIOPSY • CONTRAINDICATIONS: • Coagulation Disorders • Thrombocytopenia • Uremic Platelet Dysfunction(relative contraindication) • Uncontrolled hypertension(relative risk, maintain B.P<140/90) • Solitary Kidney (open biopsy is procedure of choice) • Advanced age and Pregnancy are NOT a contraindication

  13. RENAL BIOPSY • COMPLICATIONS: • Intrarenal Renal and perinephric Hematomas(60-80%) • Bleeding causing hypotension(1-2%),requiring transfusion (6%) • AV fistula (4-18%) • Perirenal Soft Tissue Infection(0.2%).

  14. Treatment of Lupus Nephritis • IMMUNOSUPPRESIVE THERAPY: • Cyclophosphamide • PREDNISONE • Mycophenolatemofetil (MMF) • Other Drugs • Azathioprine • Cyclosporine • Rituximab

  15. Side effects of medication . • Cyclophosphamide: • Pancytopenia (to check cbc every two weeks) • Predispose to infection by bonemarrow depression • Premature amenorrhea,Permanent infertility • Increases the risk of malignancy • Bladder toxicity • Hyponatremia due to SIADH

  16. Mycophenolatemofetil (MMF) • It is substantially more expensive then other drugs • Cytopenias: cbc first 2 weeks then every 6 weeks • Association with developing CNS lymphoma. • Antacids and Iron Supplements decrease absorption of MMF

  17. AZATHIOPRINE : • Bone Marrow Suppression • Infection • Malignancy

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