Lupus Nephritis Clinical Trials, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Caus

Описание: Three adults with lupus nephritis present with varying symptoms including changes in renal function, proteinuria, and new neurologic features. How should clinicians approach distinguishing the underlying causes of these kidney abnormalities? What clinical findings and historical details are most important when evaluating lupus nephritis patients with complex presentations and recent medication changes?

VIDEO INFO
Category: Lupus Nephritis Clinical Trials, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Causes, Diagnosis, and Management, Nephrology: Kidney Disease Diagnosis and Management
Difficulty: Moderate - Intermediate level - Requires solid foundational knowledge
Question Type: Differential Testing
Case Type: Multi Patient

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QUESTION
Three adults with SLE kidney involvement are reviewed at a combined nephrology-rheumatology visit where trial-aligned agents are available. Patient A is a 46-year-old woman with limited cutaneous scleroderma overlap who began voclosporin 6 weeks ago on a background of MMF 1.5 g/day and hydroxychloroquine 200 mg twice daily. Vitals: pulse 78, temperature 36.0 degreesC, respirations 10, blood pressure 112/62, SpO2 99%....

OPTIONS
A. Perform repeat kidney biopsy with ISN/RPS class and NIH activity/chronicity indices to distinguish active immune-complex disease from calcineurin-inhibitor toxicity and chronic scarring before altering therapy.
B. Trend anti-dsDNA and C3/C4 weekly for a month and escalate immunosuppression if titers worsen despite stable UPCR, adding monthly UPCR and BMP monitoring while deferring biopsy until the prednisone taper is complete.
C. Order contrast-enhanced CT of abdomen and pelvis to evaluate renal cortical enhancement and exclude renal vein thrombosis as the cause of proteinuria while continuing current immunosuppression.
D. Measure 24-hour urine protein and albumin excretion with urinary microscopy to better quantify nephrotic burden and avoid invasive testing until proteinuria exceeds 10 g/day or normalizes spontaneously.

CORRECT ANSWER
A. Perform repeat kidney biopsy with ISN/RPS class and NIH activity/chronicity indices to distinguish active immune-complex disease from calcineurin-inhibitor toxicity and chronic scarring before altering therapy.

EXPLANATION
When renal function worsens on a calcineurin inhibitor while proteinuria and serologies are discordant, histology is required to differentiate active immune-complex GN from CNI nephrotoxicity and chronic scarring. Repeat biopsy with ISN/RPS class and NIH activity/chronicity indices is the only modality that reliably separates these processes and should precede therapeutic redirection, per KDIGO 2024 and ACR 2025.

Serial serologies alone risk misclassification because complement and anti-dsDNA trajectories imperfectly correlate with intrarenal activity; imaging (e.g., contrast-enhanced CT) is neither specific nor indicated for this differential; and protein quantification (spot or 24-hour) does not distinguish activity from toxicity....


Further reading:

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