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

Описание: A pregnant woman in her first trimester with a history of systemic lupus erythematosus and recent class IV lupus nephritis presents with rising blood pressure, worsening edema, and persistent proteinuria, despite ongoing immunosuppressive therapy. Severe weather delays her transfer to a tertiary center, and telehealth is unavailable. How should clinicians assess and address her acute complications in this limited-resource rural emergency setting, and what clinical factors are most important in guiding initial management?

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: Treatment Failure
Case Type: Resource Limited

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QUESTION
A 29-year-old pregnant woman (G2P0, prior early miscarriage) at 13 weeks by ultrasound presents to a rural emergency department during an ice storm with progressive edema, rising blood pressure, and persistent proteinuria despite adherence to prednisone 20 mg/day and azathioprine 100 mg/day started 6 weeks ago for biopsy-proven class IV lupus nephritis diagnosed 2 months prior to conception....

OPTIONS
A. Add tacrolimus 0.05-0.1 mg/kg/day in two doses with trough-guided titration; continue hydroxychloroquine, taper prednisone, start aspirin 81 mg/day.
B. Switch to mycophenolate mofetil 1 g twice daily because it reduces proteinuria more rapidly than calcineurin inhibitors and is preferred in pregnancy.
C. Begin intravenous cyclophosphamide 500 mg every 2 weeks now to induce remission despite first-trimester fetal risks in this rural ED setting.
D. Start belimumab 10 mg/kg i.v. every 2 weeks for 3 doses then every 4 weeks as the primary induction approach in the first trimester.

CORRECT ANSWER
A. Add tacrolimus 0.05-0.1 mg/kg/day in two doses with trough-guided titration; continue hydroxychloroquine, taper prednisone, start aspirin 81 mg/day.

EXPLANATION
This first-trimester patient with biopsy-proven class IV LN has worsening edema, proteinuria (UPCR 2.3 mg/mg), falling complements, rising anti-dsDNA, and increased creatinine to 1.8 mg/dL (eGFR 38.6 mL/min/1.73 m2) despite prednisone and azathioprine. In a rural ED with delayed transfer and no infusion capability, adding an oral calcineurin inhibitor is the most practical, pregnancy-compatible intensification. Tacrolimus at 0.05-0.1 mg/kg/day in two divided doses with trough-guided titration can reduce proteinuria and control disease activity, while hydroxychloroquine should be continued, prednisone tapered as feasible, and aspirin 81 mg/day initiated to reduce preeclampsia risk. This approach aligns with KDIGO 2024 and ACR 2025 LN guidance for pregnancy-safe therapy.

Switching to mycophenolate is unsafe due to teratogenicity. Intravenous cyclophosphamide in the first trimester poses high fetal risk and is not feasible without infusion services; it is reserved for severe, refractory, or life-threatening disease after careful consideration, often later in gestation if necessary....


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