SLE + Lupus nephritis (UKM Long Case + Notes)

Question 1

State the investigation findings to establish nephrotic syndrome

Answer 1

24-hour urine protein collection or more practically spot urine protein : creatinine ratio (Urine PCR)
- Nephrotic range proteinuria : proteinuria >3.5

Serum albumin level -> HYPOALBUMINEMIA

Question 2

How do we confirm the diagnosis of lupus nephritis?

Answer 2

UFEME -> cellular casts

Renal biopsy
- Findings: deposition of immune complexes in glomeruli
- Investigations before biopsy: RENAL US to determine cortical thickness (must be at least 1cm to allow renal biopsy)

Question 3

How do we confirm the diagnosis of SLE?

Answer 3

Systemic Lupus International Collaboration Clinic (SLICC) criteria

Diagnosis is made when
- >4 criteria are met, with at least one from clinical and one from immunological
- Biopsy proven lupus nephritis with positive ANA or anti-dsDNA

Question 4

List the staging of lupus nephritis based on the pathological assessment of kidney tissue sample and its corresponding treatment

Answer 4

Generally:
- Stage 1 and 2 do not require immunosuppressive treatment, while stage 4 requires RRT
- Stage 3 and above require immunosuppressive treatment

Question 5

Explain on the immunosuppressive treatment of lupus nephritis

Answer 5

In all patients, HYDROXYCHLOROQUINE should be used

Question 6

List the adjunctive treatment in lupus nephritis

Answer 6

• ACEI/ARB for all patients with urine PCR >500 mg/g or with HPT (Keep BP <130/80 mmHg)
• Statins if required (assessed by lipid level and 10 years CVS disease risk)
• Vaccination?

Question 7

How to treat refractory disease of lupus nephritis?

Answer 7

• Evaluate alternative causes
• Assess compliance
• Treatment: RITUXIMAB

Question 8

List the medications given for SLE

Answer 8

• Hydroxychloroquine (Recommended in all SLE patients)
• Corticosteroids
• Immunosuppressive therapy
• Biological agents

Question 9

List 2 biological agents used in SLE patient

Answer 9

Question 10

State the high-risk features of antiphospholipid syndrome

Answer 10

• Multiple antiphospholipid antibodies positivity
• Positive lupus anticoagulant
• Persistently high titer antibodies
• History of thrombotic event or obstetric event
• Co-existing SLE
• Presence of other CVS risk factors

Question 11

Describe on the management plan for antiphospholipid syndrome

Answer 11

Identify the high risk features

Control CVS risk factors is paramount
- Smoking cessation
- Optimize BP
- Optimize blood glucose and lipid
- Regular physical activity

Thromboprophylaxis
- Primary thromboprophylaxis with low dose aspirin considered in patients with
1. SLE with high risk features
2. History of obstetric event

Question 12

List the clinical signs and laboratory findings of SLE flare

Answer 12

Clinical signs
- Joint pain
- Increasing fatigue
- Skin rashes
- Oral ulcers
- Lower limb swelling

Laboratory findings
- Thrombocytopenia
- High level of anti-dsDNA
- Low complement level
- Proteinuria

Question 13

State the MOA and side effects of the following drugs used in SLE
1. Methotrexate
2. Azathioprine
3. Cyclophosphamide
4. Mycophenolate mofetil
5. Calcineurin inhibitors

Answer 13