A 50-year-old woman with SLE presents to the emergency depament with complaints of headache and fatigue. Her past manifestations of SLE have been ahralgias, haemolytic anaemia, malar rash, and mouth ulcers, and she is known to have high titres of antibodies to dsDNA. She currently is taking prednisone, 5 mg daily, and hydroxychloroquine, 200 mg daily. On examination, she is found to have a BP 190/110 mmHg with a HR 98 bpm. A urinalysis shows 25 RBCs per HPF with 2+ proteinuria. No RBC casts are identified. Her BUN is 90 mg/dL, and creatinine is 2.8 mg/dL (baseline 0.8 mg/dL). She has not previously had renal disease related to SLE and is not taking NSAIDs. She denies any recent illness, decreased oral intake, or diarrhoea. What is the most appropriate next step in the management of this patient?
This patient is presenting with acute lupus nephritis. It is Immune complex mediated disease. M/C/C of death in patients of SLE. The urinalysis shows evidence of active nephritis with hematuria and proteinuria. Even in the absence of red blood cell (RBC) casts, therapy should not be withheld to await biopsy results. Factors Governing progression to Lupus Nephritis: Increased Progression Decreased Progression Hypeension Proteinuria Increase dsDNA titer Low C3 complement Thrombocytopenia 1. Anti RO antibody 2. Anti LA antibody The mainstay of treatment for any life-threatening or organ threatening manifestation of SLE is high-dose systemic glucocoicoids. Addition of immunosuppressive agents (cyclophosphamide, azathioprine, mycophenolate mofetil) is recommended to treat serious complications of SLE, but their effects are delayed for 3-6 weeks after initiation of therapy, whereas the effects of glucocoicoids begin within 24 hours. Thus, these agents alone should not be used to treat acute serious manifestations of SLE.
Initiate cyclophosphamide, 500 mg/m2 body surface area intravenously (IV), and plan to repeat monthly for 3-6 months.
Initiate haemodialysis.
Initiate high-dose steroid therapy (IV methylprednisolone, 1000 mg daily for 3 doses, followed by oral prednisone, 1 mg/kg daily) and mycophenolate mofetil, 2 g daily.
Initiate plasmapheresis
Systemic Lupus Erythematous