It’s Not Lupus…Except When It Is!

After a week-long hiatus we are back folks!

Yesterday we presented a case of a patient with untreated SLE who presented with the following:

  1. Diffuse joint pain and swelling, that were non-erosive on x-ray
  2. DAT+, IgG+ anemia
  3. ANA 1:640!
  4. +anti-dsDNA/+anticardiolipin screen
  5. UPCR of >13g/day with an AKI
  6. Pleuritic chest pain, likely representing serositis

Taken together, she meet at least 6/11 criteria for lupus by ACR (only 4/11) are needed), which we briefly reviewed:

ACRlupus

We then reviewed the ISN/RPS histological classification of lupus nephritis and while it is full of technical language, we simplified it greatly as the following:

  • Class 1&2 – mesangial disease
    • conservative treatment with ACE-i
  • Class 3&4 – proliferative disease
    • treat with steroids + (mycophenolate OR cyclophosphamide)
  • Class 5 – membranous lupus nephritis (AKA membranous nepropathy-like with significant proteinuria
    • treat similarly to proliferative disease, though some experts also consider involving use of a calcineurin inhibtor, extrapolating its benefit from idiopathic membranous nephropathy
    • important to recognize that these classes are not stages, and you can have combined class 3 and class 5 disease OR you can have isolated class 5 disease for example that converts later to combined class 4 and 5 disease – illustrating the importance of a repeat biopsy in situations of acute decline in eGFR or increase in proteinuria
  • Class 6 – advanced sclerosing lupus nephritis
    • >90% of glomeruli on LM are globally sclerosed with no residual activity
    • conservative therapy until RRT needed

For a further review of lupus nephritis, please see the previous, excellent post:

https://scvmcmed.com/2019/02/12/lupus-nephritis/

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