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SEGMENTAL PROLIFERATIVE LUPUS NEPHRITIS in RENAL BIOPSY. PROGNOSIS?

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A 23 female has been diagnosed to have Systemic Lupus Erythmatosus SLE 2.5 years ago.
Renal biopsy in october 2012 showed diffuse segmential proliferative lupus nephritis (WHO class IV-s) , activity index 12/24, chronicity index 2/12.
she adminstered at that time Rituximab 1gram and another one after 2 weeks.
she is now on the following medications:
Hydroxychloroquine sulphate 200mg.
mycophenolate mofetil
calcium 800mg
prednisolone 20mg
bisoprolol fumarate 5mg + hydrochlorothizine 12.5mg.
olmesertan 4mg.

The problem now that renal function keeps deteriorating. Creatinine is 2.3 mg/dl ( normal is 0.5-1.2). Potassium is 5.5 mmol/L. Protien/creatinine ratio is 0.53.

Abdominal ultrasonography of kidneys shows normal kidney size but there is bilateral increase in cortical echogencity with preserved medullary echopattern and reveal good CM differentiation (parenchymal thickness right: 20mm, left 25mm), no stones or back pressure , no perirenal collection findings suggesting of glomerulonephritic disease.

On ELISA, anti DNA Abs (ELISA A) was positive 198.
ANA Positive 1/80. Method used was indirect immunoflouroscence.

IgG positive ++ segmental messangial.
igM positive +++ membrane messangial.
igA positive ++ messangial membrane.
C3 positive +++ segmental messangial.

More recently, she has been adviced to have a chemotheraputic treatment to reduce disease progression.
She is afraid of chemotherapy and she wants to know if this is the right theraputic approch available to help her case.
What the other theraputic approaches which are available and can help to improve her case.
finally, what is the prognosis of this medical case?

Many thanks.

Category: Nephrologist

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Category: Pediatric Nephrologist
 27 Doctors Online

Hello,
Thank you for your query at DoctorSpring.com
SLE is a systemic disease which involves several parts of the body and affects the young women predominantly( unfortunately).
I felt that she has been diagnosed with lupus nephritis a bit late as evidenced by significant chronicity index. It suggests that the damage to the has a permanent features in that and they are likely to progress. Activity index suggests that she would require the higher immunosuppression which she received in the form of rituximab. She has been taking all drugs appropriately except a slightly higher dose of steroids, which can lead to few steroid complications. We dont have to look at the raising creatinine alone to increase the immunosuppression drugs as she is adequately immusuppressed. there should not be any knee jerk reaction to increasing creatinine. She should have been given Inj Cyclophosphamide before itself instead of rituximmab but must have been with held looking at the younger age. (Did she conceive before ? how many children does she have?).
Prognosis would be not so good as immunological destruction can take any turns and i feel that she should be doing good with MMF. Excess immusosupressive drug therapy can put her in to unnecessary complications also. We should weight risk versus the benefit. T She has a tendency to progress very slowly and dont get disheartened by looking at the creatinine alone as she can be stable at the same creatinine level for several years unless you change the drugs on your own , switch over to alternative forms of therapies etc. ( please don't do that as they are very harmful to kidneys).
Feel free to discuss further,
Regards.


Patient replied :

Thanks for your reply. I just want to know what MMF (mentioned in your kind answer) stands for?
Second I just want to give you further information which mighr give you wider picture about activity and spreading of the disease.
her weight was 51 kg at the time of disease diagnosis 3 years ago. Her weight went up to 69 kg after putting her on treatments including steroid. 3 months ago she suffered from nausea and vomiting (she has been told that disease is active and starts to involve GIT and gut). As a result, her weight went down yo 61kg.
her doctor now wants to put her on Solumedrol 1g followed by cudophosphamide 1gram. what do you think about this treatments? If they are suitable for her case, what is the proper dose and for how long?
Do you have any other treatment suggestions or alternatives?
Finally, can I please know your name and breif information about you?
Many thanks


Hello,
MMF stands for mycophenolate mofetil. It can produce loose stools and stomach pain e.t.c but otherwise effective and safe.
Steroids can produce such a weight gain and few more complications related to that. Steroids should be given carefully and cautiously to avoid such complications and effective use. I personally feel that solumedrol and 1 gm of cyclophosphamide are a bit high and as I told you that along with the impulse increase in immunosuppressive can be harmful and futile. According to me MMF is the best alternative.
Best Regards,
Dr. Sree Bhushan Raju, DM Nephrology.


Patient replied :

Hi Doctor In your answer you said that MMF is the best alternative for cyclophosphamide. I think she is already on MMF. so what other suggessions you reccomend? Rituxamab for example? What dose and for how long?
Thanks


Hi,

Yes. MMF is good compared to all other drugs in maintenance therapy. Better not to give rituximab again. There is a kind of damage took place already demonstrated by chronicity index. As I said, any knee jerk reaction in hiking the immunosuppression would result in complications rather than of any use. She requires to be on 2 gm per day of MMF initially followed after few months by 1.5 gm per day. HCQ and a statin , vitamin D etc are useful.
BP control and weight reduction would make the kidney better. Wait and watch creatinine and if required ( in case of slightly rapid rise of creatinine would require kidney biopsy again )




Regards
Dr Sree Bhushan Raju


Dr. Sree Bhushan Raju
Category: Pediatric Nephrologist
Experience: 
FISN : Fellowship of Indian Society of Nephrology(ISN), 2012
FIACM : Fellowship of Indian Association of Clinical Medicin(IACM), 2012
FICP: Indian College of Physicians Association of Physicians of India, 2012
Fellowship: DM, DNB, All India Institute of Medical Sciences, New Delhi, 2002
Residency: MD, General Medicine, Nizam's Institute of Medical Sciences, 1998
Medical School: MBBS, Gandhi Medical College, 1994
Dr. Sree Bhushan Raju and 4 other Medical Specialists are ready to help you

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