Lupus Nephritis and Pregnancy, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Causes

Описание: A 32-year-old pregnant woman with a history of biopsy-proven lupus nephritis, currently stable on hydroxychloroquine and azathioprine, presents for routine maternal-fetal and nephrology follow-up. She reports mild symptoms including lower-extremity edema and morning nausea. How should her current clinical findings and laboratory data guide your assessment of maternal and fetal risk during pregnancy? What factors would you monitor to anticipate complications?

VIDEO INFO
Category: Lupus Nephritis and Pregnancy, 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: Typical Presentation

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QUESTION
A 32-year-old woman at 14 weeks gestation (G1P0) presents for combined maternal-fetal medicine and nephrology follow-up of systemic lupus erythematosus with prior biopsy-proven lupus nephritis. She conceived after 14 months of clinical quiescence. Vitals today: pulse 102/min, temperature 37.3 degreesC, respirations 18/min, blood pressure 119/76 mmHg, oxygen saturation 98% on room air....

OPTIONS
A. With quiescent class III-V lupus nephritis at conception, flare risk is moderate and clusters late and postpartum; continuing hydroxychloroquine reduces flares and is considered safe for the fetus.
B. Severe renal flares occur in most pregnancies despite quiescence, so routine high-dose prednisone through all trimesters is recommended to prevent maternal and neonatal complications.
C. If lupus nephritis is quiet before conception, pregnancy eliminates preeclampsia risk and proteinuria remains unchanged compared with healthy gravidas throughout gestation.
D. Immune changes of pregnancy reliably suppress lupus activity, allowing hydroxychloroquine to be stopped after the first trimester without increasing renal flare risk.

CORRECT ANSWER
A. With quiescent class III-V lupus nephritis at conception, flare risk is moderate and clusters late and postpartum; continuing hydroxychloroquine reduces flares and is considered safe for the fetus.

EXPLANATION
This gravida conceived after sustained quiescence of ISN/RPS class IV lupus nephritis, remains on hydroxychloroquine and pregnancy-compatible maintenance therapy (azathioprine), and has stable creatinine, low anti-dsDNA, normal complements, bland urinary sediment, and a modest UPCR of 0.3 g/g-features arguing against active nephritis. The expected natural history in such patients is a moderate flare risk that clusters in late gestation and early postpartum, with lower flare rates when hydroxychloroquine is continued. This aligns with contemporary guidance emphasizing conception during quiescence ( =6 months), continuation of hydroxychloroquine throughout pregnancy, and use of pregnancy-compatible agents such as azathioprine or tacrolimus. Per KDIGO 2024 and ACR 2020 reproductive health guidance, hydroxychloroquine is considered safe for the fetus and reduces lupus activity during pregnancy.

By contrast, claims that high-dose prednisone should be given routinely across all trimesters in quiescent disease are inconsistent with modern risk-reduction strategies and expose the mother and fetus to avoidable harms (maternal diabetes, hypertension, infection; fetal growth concerns)....


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