Clinical presentation and monitoring of lupus nephritis

Abstract

The diversity of clinical presentations of lupus nephritis parallel the diversity of pathologic lesions seen in the kidneys of patients with SLE. Renal manifestations range from asymptomatic hematuria or proteinuria to overt nephritic and nephrotic syndromes, rapidly progressive glomerulonephritis, and chronic renal failure. Subclinical nephropathy both during presentation and during monitoring of disease activity is frequently missed because of the notorious unreliability of routine screening urinalyses performed in high-throughput clinical pathology laboratories. Requisitions for urine microscopy should be flagged for special attention in patients at risk for lupus nephritis. Depression of classic complement pathway components and high titers of anti-DNA, anti-nucleosome, or anti-C1q antibodies identify patients are increased risk of renal involvement or flares of nephritis. Several disease activity and damage indexes are available, but they are mostly used in clinical research setting and none has achieved wide use for standard clinical practice.

Keywords

lupus nephritis lupus serologies renal function urine sediment

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References

Houssiau FA. Management of lupus nephritis: an update . J Am Soc Nephrol 2004; 15: 2694-2704 .

Balow JE , Boumpas DT , Austin HA III. Lupus Nephritis. In Brady HR , Wilcox CS eds. Therapy in Nephrology and Hypertension. 2nd edition. London: WB Saunders , 2003: 153-164.

Updated criteria: Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus [letter] . Arthritis Rheum 1997; 40: 1725-1725 .

Balow JE , Boumpas DT , Austin HA III. Systemic lupus erythematosus and the kidney. In Lahita RG ed. Systemic Lupus Erythematosus. 4th edition. Elsevier: Amsterdam , 2004; 877-912.

Lewis EJ , Schwartz MM , Korbet SM eds. Lupus nephritis. Oxford: Oxford University Press , 1999: 1-315.

Levey AS , Coresh J , Balk E et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification . Ann Intern Med 2003; 139: 137-147 .

Fogazzi GB , Ponticelli C , Ritz E. The Urinary Sediment, 2nd edition. Oxford: Oxford University Press , 1999; 1-188.

Rasoulpour M , Banco L , Laut JM , Burke GS. Inability of community-based laboratories to identify pathological cast in urine samples . Arch Pediatr Adolesc Med 1996; 150: 1201-1204 .

Chitalia VC , Kothari J , Wells EJ et al. Cost-benefit analysis and prediction of 24-hour proteinuria from the spot urine protein-creatinine ratio . Clin Nephrol 2001; 55: 436-447 .

10.

Christopher-Stine L , Petri M , Astor BC , Fine D. Urine protein-tocreatinine ratio is a reliable measure of proteinuria in lupus nephritis . J Rheumatol 2004; 31: 1557-1559 .

11.

Chan TM , Li FK , Tang CS et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis . N Engl J Med 2000; 343: 1156-1162 .

12.

Korbet SM , Lewis EJ , Schwartz MM et al. Factors predictive of outcome in severe lupus nephritis . Am J Kidney Dis 2000; 35: 904-914 .

13.

Illei GG , Takada K , Parkin D et al. Renal flares are common in patients with severe proliferative lupus nephritis treated with pulse immunosuppressive therapy . Arthritis Rheum 2002; 46: 995-1002 .

14.

Hahn BH. Antibodies to DNA . N Engl J Med 1998; 338: 1359-1368 .

15.

Berden JH. Lupus nephritis (Nephrology Forum) . Kidney Int 1997; 52: 538-558 .

16.

Trouw LA , Groeneveld TW , Seelen MA et al. Anti-C1q autoantibodies deposit in glomeruli but are only pathogenic in combination with glomerular C1q-containing immune deposits . J Clin Invest 2004; 114: 679-688 .

17.

Marto N , Bertolaccini ML , Calabuig E et al. Anti-C1q antibodies in nephritis: correlation between titres and renal disease activity and positive predictive value in systemic lupus erythematosus . Ann Rheum Dis; published ahead online 29 July 2004 at http://wd.bmjjournals.com/cgi/reprint/and.2004.0249453v1

18.

Manzi S , Ahearn JM , Salmon J. New insights into complement: a mediator of injury and marker of disease activity in systemic lupus erythematosus . Lupus 2004; 13: 298-303 .

19.

Bootsma H , Spronk P , Derksen R et al. Prevention of relapses in systemic lupus erythematosus . Lancet 1995; 345: 1595-1599 .

20.

Urowitz MB , Gladman DD. Clinical monitoring. In The clinical management of systemic lupus erythematosus, 2nd edition. Schur PH ed. Lippincott-Raven: Philadelphia , 1996: 225-233.

21.

Strand V , Gladman D , Isenberg D et al. Endpoints: consensus recommendations from OMERACT IV. Outcome measures in rheumatology . Lupus 2000; 9: 322-327 .