SLE- LN Patho and Treatment

Question 1

How does LN occur?

Answer 1

Kidney inflammation

Question 2

How can kidney inflammation occur?

Answer 2

Intravascular deposition of immune complexes in glomeruli
Formation of immune complexes on self-antigens on glomerular basement membrane

Question 3

Diagnostic criteria for LN

Answer 3

Persistent proteinuria and/or cellular casts, renal biopsy and histology to confirm

Question 4

Presentation of LN

Answer 4

Foamy urine, peripheral edema, concomitant HTN

Question 5

There’s 6 classes of LN, but which 3 are the worst?

Answer 5

III, IV, VI

Question 6

More severe forms of LN may require what?

Answer 6

Immunosuppression or preparation for transplant

Question 7

LN induction therapy

Answer 7

Immunosuppressant (MMF or CYC) plus a steroid

Question 8

Remission for LN

Answer 8

Taper doses and switch immunosuppressant PRN

Question 9

Proliferative LN is what classes of LN?

Answer 9

III, IV

Question 10

What treatment can you start in proliferative LN in all kinds of severity?

Answer 10

GC + MMF
GC + low-dose IV CYC
GC + MMF + TAC

Question 11

What treatment can you also use in proliferative LN in severe presentations?

Answer 11

GC + high-dose IV CYC (but can try the other 3 listed for less severe presentations)

Question 12

When do you assess the response to proliferative LN treatment?

Answer 12

3-12 months

Question 13

If there is a response to proliferative LN after 3-12 months, what do you do?

Answer 13

Start MMF or AZA, and if there’s no relapse, continue the treatment

Question 14

If there is no response to proliferative LN after 3-12 months or there’s a relapse, what do you do?

Answer 14

Switch to alternate induction therapy, add TAC to MMF, or ritixumab

Question 15

Steroid dosing in proliferative LN

Answer 15

Bolus of IV methylprednisolone (IV pulse), then PO prednisone 0.3-0.5mg/kg/day

Question 16

Class V LN treatment: step 1

Answer 16

Assess if UPr is < or >3g/24hr

Question 17

If UPr is <3g/24hr, what do you start?

Answer 17

RAAS blockade, consider GC and MMF

Question 18

If UPr is >3g/24hr, what do you start?

Answer 18

RAAS blockade, GC and MMF

Question 19

Step 2 of Class V LN treatment when UPr is <3g/24hr

Answer 19

Assess response at 3-12 months

Question 20

If there is a response, what do you do?

Answer 20

Continue same treatment with gradual taper of the GC

Question 21

If there is no response, what do you do (UPr <3g/24hr)?

Answer 21

GC and MMF

Alternative is IV-CYC or CNI

Question 22

Subsequent therapy for Class V LN with UPr is >3g/24h

Answer 22

GC and MMF

Alternative is IV-CYC or CNI

Question 23

Step 2 of LN Class V treatment when UPr is >3g/24hr

Answer 23

Assess response at 3-12 months

Question 24

If there is no response, what do you do (UPr >3g/24h)?

Answer 24

CNI monotherapy or add on to MMF or high-dose IV-CYC or rituximab

Question 25

If there is a response, what do you do (UPr >3g/24hr)?

Answer 25

Continue same treatment with gradual tapering of GC

Question 26

LN Care Points: ACEi/ARB

Answer 26

Use in SLE patients who have glomerular disease and persistent proteinuria (≥0.5g/24h) and/or HTN (goal ≤130/80)

Question 27

LN Care Points: statins

Answer 27

Use in SLE patients when LDL >100mg/dl