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

Описание: A 28-year-old pregnant woman with a history of lupus nephritis, previously in remission but now experiencing morning nausea, increased urinary frequency, mild proteinuria, and stable vital signs at 14 weeks gestation, presents for evaluation. How should her clinical features, past disease activity, and current laboratory findings inform your management approach during pregnancy and postpartum? What considerations are key in distinguishing physiologic gestational changes from lupus flare in this scenario?

VIDEO INFO
Category: Lupus Nephritis Clinical Trials, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Causes, Diagnosis, and Management, Nephrology: Kidney Disease Diagnosis and Management
Difficulty: Expert - Expert level - For those seeking deep understanding
Question Type: Natural History
Case Type: Pregnant Patient

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QUESTION
A 28-year-old pregnant woman at 14 weeks gestation (G1P0) with SLE and prior class IV-S LN achieved complete renal response 18 months ago on mycophenolate mofetil 1 g twice daily and hydroxychloroquine 200 mg twice daily. Planning conception, she switched 3 months prior to azathioprine 2 mg/kg/day and continued hydroxychloroquine; ACE inhibitor was stopped. She now reports morning nausea, stable weight, and increased urinary frequency without dysuria....

OPTIONS
A. Continue hydroxychloroquine and switch mycophenolate to azathioprine preconception or early in pregnancy; avoid initiating belimumab or voclosporin; monitor UPCR and eGFR each trimester and postpartum, with flare risk highest in the first 3-6 months after delivery.
B. Start belimumab IV 10 mg/kg in the second trimester for steroid-sparing control and resume mycophenolate 1 g twice daily in the third trimester to reduce proteinuria prior to delivery; discontinue hydroxychloroquine and ACE inhibitors to avoid fetal complications. Immediately.
C. Add voclosporin 23.7 mg twice daily in the first trimester for rapid proteinuria reduction, targeting UPCR =0.5 g/g by week 24, and continue ACE inhibitor therapy at a reduced dose to preserve eGFR during gestation.
D. Stop all immunosuppression at confirmation of pregnancy to minimize fetal exposure, manage with sodium restriction alone, and plan to reintroduce therapy only after delivery if proteinuria exceeds 3.5 g/day or complements fall.

CORRECT ANSWER
A. Continue hydroxychloroquine and switch mycophenolate to azathioprine preconception or early in pregnancy; avoid initiating belimumab or voclosporin; monitor UPCR and eGFR each trimester and postpartum, with flare risk highest in the first 3-6 months after delivery.

EXPLANATION
This pregnant patient with prior class IV-S LN is in remission on azathioprine and hydroxychloroquine with UPCR 0.22 g/g and eGFR 121 mL/min/1.73 m2, consistent with gestational hyperfiltration. KDIGO 2024 and ACR 2024 recommend continuing hydroxychloroquine and using azathioprine rather than mycophenolate during pregnancy, with trimester and postpartum monitoring. Initiating belimumab or voclosporin in pregnancy lacks robust randomized safety data for LN; ACE inhibitors/ARBs remain contraindicated.

Incorrect choices either start teratogenic/insufficiently studied agents or withdraw essential therapy. Starting belimumab and resuming mycophenolate in late pregnancy is inappropriate and discontinuing hydroxychloroquine increases flare risk; ACE inhibitors are contraindicated....


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