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

Описание: An independent 96-year-old woman presents with two months of ankle swelling, foamy urine, and periorbital puffiness. Her labs reveal significant proteinuria, low serum albumin, hematuria, and positive autoimmune serologies, while a kidney biopsy shows granular immune deposits and endocapillary proliferation. Facing this complex clinical scenario, what factors should guide your interpretation of her renal disease? How can you classify her glomerular pathology using current diagnostic criteria?

VIDEO INFO
Category: Lupus Nephritis Clinical Trials, Lupus Nephritis: Diagnosis and Management, Glomerulonephritis: Causes, Diagnosis, and Management, Nephrology: Kidney Disease Diagnosis and Management
Difficulty: Hard - Advanced level - Challenges experienced practitioners
Question Type: Diagnosis - Identify conditions based on clinical presentation
Case Type: Common Scenario

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QUESTION
A 96-year-old woman reports 2 months of ankle swelling and foamy urine. She lives independently, walks indoors daily, and prepares her own meals. She follows a vegetarian diet and quit alcohol 5 years ago. She has a remote history of cryptococcal meningitis treated successfully in midlife and a remote period of injection drug use. Family history is notable for a niece with systemic lupus erythematosus....

OPTIONS
A. Lupus nephritis, ISN/RPS 2018 class IV diffuse proliferative with active lesions and mild chronicity on biopsy, consistent with adult proliferative disease.
B. Primary membranous nephropathy due to anti-PLA2R with secondary lupus serologies explaining hypocomplementemia and positive anti-double-stranded DNA.
C. IgA nephropathy with superimposed hypertensive nephrosclerosis accounting for wire-loop lesions and the granular full-house immunofluorescence pattern.
D. C3 glomerulopathy with nephritic sediment and low complements, with full-house staining attributed to nonspecific immune trapping rather than immune complexes.

CORRECT ANSWER
A. Lupus nephritis, ISN/RPS 2018 class IV diffuse proliferative with active lesions and mild chronicity on biopsy, consistent with adult proliferative disease.

EXPLANATION
This patient has nephritic-range proteinuria with hematuria and red cell casts, high-titer anti-double-stranded DNA, hypocomplementemia, and a biopsy showing diffuse endocapillary hypercellularity, wire-loop-type subendothelial deposits, crescents, and full-house immunofluorescence. Electron microscopy confirms abundant subendothelial and mesangial immune-complex deposits. These features define a diffuse proliferative lupus nephritis under the current ISN/RPS 2018 revision; activity is present (endocapillary hypercellularity, wire loops, crescents) with only mild chronicity ( 10% IF/TA). eGFR is moderately reduced, consistent with active proliferative disease in an older adult.

Primary membranous nephropathy is unlikely because anti-PLA2R is negative and the biopsy lacks dominant subepithelial deposits typical of primary membranous; full-house staining points away from primary membranous. IgA nephropathy does not produce full-house staining or diffuse wire-loop subendothelial deposits....


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