1921-the kidney in lupus lfgw june08 handout

7/30/2019 1921-The Kidney in Lupus Lfgw June08 Handout

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Kidney Disease in SystemicLupus Erythematosus (SLE)

Gabor Illei, MD, MHS

National Institute [email protected]


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Clinical manifestations of SLE

Variable: from mild to life

threatening

Onset: gradual (more

common) or acute

Remitting-relapsing

course

Kidney is the most

common major organ

involved (lupus nephritis)


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Systemic lupus erythematosus

Autoimmune Disease

The immune system is turning against itself and is

attacking the bodys own cells

This leads to inflammation pain, swelling, redness, heat and loss of function


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Lupus is a disease characterized

by inflammation

Arthritis Serositis Dermatitis


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Why should we worry about

kidney problems

50% of all lupus patients will have kidney

involvement during their life of these, 50 % will have serious kidney disease

Patients may not be aware that kidney

problems exist


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What is lupus kidney disease?

Also called lupus nephritis or

glomerulonephritis Inflammation in the kidney

The inflammation may be:

BAD or NOT SO BAD

Could result in scarring

BAD or NOT SO BAD

Worse case = Renal Failure


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Why is inflammation undesirable?

If untreated:

Scarring, dysfunction, and loss of function results.

We dont want to have scarring in the kidney


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The Normal Kidney

kidney

ureter

bladder

urethra


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Function of the Normal Kidney

Major waste management plant of the

body Filters and excretes metabolic waste products

Detoxifies and eliminates toxins

Regulates fluid and electrolyte balance

Important role in blood pressure regulation

Regulates red blood cell production


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Functional unit:nephron

About 1.2 million

nephrons per kidneyEach nephron has 2

parts

Glomerulus: filtering

unit Tubules: reabsorbs and

secretes electrolytes,glucose and aminoacids

glomerulus tubules


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Glomerulus

Blood components arefiltered through amembrane (called a

basement membrane)which acts like a sieve

Small molecules easilypass through this filter

Larger molecules, likecells and proteins abovea certain size, do not passthrough this membranein healthy people


urineBasement

membrane


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How does lupus damage the

kidneys?

Autoantibodies are formed against antigens

in the glomerulus basement membrane

Circulating immune complexes bind to the

basement membrane of the glomeruli (the

sieve)

These result in inflammation of the

glomeruli (glomerulonephritis)


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How does lupus damage the

kidneys?The basement membrane is damaged by the

inflammation and its function as a sieve is lost

Appearance of protein, white and red blood cellsand casts in the urine

Low albumin levels in the blood resulting inleakage of fluid from the vessels into the tissues

(edema)Accumulation of waste proteins (uremia)

Hypertension


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How can we tell the severity

of the inflammation

Patients well-being

Physical examination

Results of blood and urine tests

Kidney biopsy


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Signs and Symptoms

Variable

Fatigue

More lupus symptoms Fluid retention (swelling in the feet, legs, hands)

Foamy urine

need tourinate more often or at night

OR nothing appears different


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Physical Findings

High blood pressure

Inflammation (joints, hair loss, oral ulcers,etc.)

signs that lupus is active

Edema

Feet, legs, hands

OR everything appears normal


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All lupus patients should:

See their health care provider routinely

Have both blood and urine examined

regularly Monitor blood pressure

Report any symptoms of lupus to their

health care provider


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Laboratory

Tests todetermine if lupus is active

Rise in the titers of anti-double stranded DNA

antibodies

Decrease in complement levels

CBC (complete blood count)

Kidney function tests

Increased blood urea nitrogen (BUN) Increased serum creatinine


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Laboratory

Urine Presence of blood in the urine

Protein: best if measured in a 24 hour urine

collection

Abnormal urine sediment (urine is centrifuged

and the analyzed under a microscope)

Red blood cells (esp. if they have an

abnormal shape)

White blood cells

Casts (dead cells retaining the tubules shape)


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Red blood cells and cast in the urine


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What happens if lupus kidney

disease is suspected? Many things will occur:

Blood and urine evaluation

Consultations with Rheumatologist,Nephrologist

Ultrasound of the kidneys

Kidney biopsy

shows a picture of how muchinflammation is present and

where it is occurring

http://www.kidneybiopsy.com/silverman.htm


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Do I really need a biopsy?

Most likely - YES depends upon the treating physician

Kidney biopsies are important to dictate how to treat

predict how long to treat

predict the chance for kidney function recovery


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Kidney Biopsy

Who does it? A kidney specialist (nephrologist)

How is it done?

A needle is inserted into the skin in the lower backguided by ultrasound or CT

A small piece of kidney is removed and sent awayfor analysis

Patients may be admitted for overnight observation

Complications Bleeding around the kidney

Infections


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The biopsy helps determine treatment

Inflammation can occur:

Diffusely

Focally

It can cause Thickening

More cells than normal

Scarring

Loss of function


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Electronmicroscopy


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Types of Lupus Nephritis

6 classes based on a WHO classification

Class I (normal) mild

Class II (mesangial) mild

Class III (focal proliferative glomerulonephritis)

moderately severe

Class IV (diffuse proliferative glomerulonephritis)

severeClass V (membranous glomerulonephritis) variable

Class VI (glomerulosclerosis) irreversible changes


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Cellcept (Mycophenolate mofetil) in

lupus nephritis

Recent study showed that Cellcept is not

better than cytoxan in inducing remission Long-term results with Cellcept are unkown

Higher relapse rate


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Cellcept

Side effects

Infections

Low white blood cell count Diarrhea

Increased risk of lymphoma ?

No effect on fertility


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Time

C3 level

DNA titer

ProteinuriaPrednisone dose

Cytoxan therapy

Monitoring Lupus Activity


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Will I get kidney disease a

second time? Perhaps

To avoid a relapse:

Take care of yourself

eat right, sleep right, avoid stress

Take your medications

Regular follow-up


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Kidney failure in lupus nephritis

Total shutdown of kidneyfunction

Fatal if not treated Treatment of kidney

failure

Dialysis

Some patients recover withtreatment and can come offdialysis

Kidney transplant

1921-the kidney in lupus lfgw june08 handout

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