CASE STUDIES

European Renal Association – European Dialysis and Transplant Association (ERA-EDTA)
in collaboration with
Renal Pathology Society (RPS)

CME Course on Renal Pathology

LUPUS NEPHRITIS: CASE PRESENTATION

Although the most severe histological forms of lupus nephritis tend to have more severe clinical manifestations renal histology cannot be predicted with any certainity from the clinical picture. As a matter of fact 31 out of 94 patients followed in our Unit with class III or IV lupus nephritis (that means 33% of patients) presented with urinary abnormalities (Table 1).

Our results are comparable to those of Cameron who reported that 11 out of 48 patients with class IV (that means 23% of patients) presented with urinary abnormalities (Table 1).

Table 1: Renal manifestations at presentation of renal disease of pts with class III and IV lupus nephritis
Renal presentation	WHO class IV (JS Cameron: Rheumatology and the Kidney 2001)		WHO class III+IV (our series)
	N.	%	N.	%
Urinary abnormalities*	11	23	31	33
Nephrotic sindrome**	18	38	26	28
Renal insufficiency	19	39	37	39
Total	48	100	94	100

*Urinary abnormalities = Non nephrotic proteinuria (<3.5g/day) and/or microscopic hematuria (>5 red blood cells per high power field)

** Nephrotic syndrome usually associated with microscopic hematuria  

Conclusions

In conclusion 1/3 of patients with the most severe histological forms of lupus nephritis present with mild urinary abnormalities. In the absence of a histological evaluation these patients could be erroneously considered as having a mild renal disease and therefore not be treated adequately.

 

The patient was submitted to renal biopsy that showed a diffuse proliferative GN (Class IV): Activity index 8, Chronicity index: 0

 

Question 2 : What would you do with therapy when a patient with diffuse proliferative lupus nephritis enters complete clinical remission?  

Treatment and outcome

After renal biopsy the patient was treated with methylprednisolone pulses, 1g/day each for 3 days followed by prednisone 0.5mg/kg/day and cyclophosphamide 1mg/Kg/day. In February 1981, three months later, the patient was in complete biological and clinical remission: Plasma creatinine 0.6mg/dl, Proteinuria 0.1g/24h. Inactive urinary sediment.

 

Question 2