| disease | Lupus Nephritis |
Lupus nephritis refers to a disease characterized by systemic lupus erythematosus combined with immune-mediated damage of varying pathological types in both kidneys, accompanied by significant clinical manifestations of renal impairment.
bubble_chart Diagnosis
I. Medical History and Symptoms
Most commonly seen in young and middle-aged women. Mild cases may present as asymptomatic proteinuria. <2.5g/d）或血尿，無水腫 、高血壓；多數病例可有蛋白尿、紅白細胞尿、管型尿或呈腎病綜合徵表現，伴有浮腫、高血壓或腎功能減退，夜尿增多較常見；少數病例起病急劇，腎功能迅速惡化。多數腎受累發生於發熱、關節炎、皮疹等腎外表現之後，重型病例病變常迅速累及漿膜、心、肺、肝、造血器官和其它臟器組織，并伴相應的臨床表現。約1/4的病人以腎臟損害為首發表現。對於生育年齡婦女有腎臟疾病時應常規檢查與本病有關的免疫血清學指標。本病診斷大多參照美國風濕病學會1982年制定的系統性紅斑狼瘡診斷標準。
II. Physical Examination Findings
Fever is common in the acute phase; most patients exhibit signs of anemia. The characteristic feature is a butterfly-shaped rash on the face. May be accompanied by joint swelling, alopecia areata, skin rashes, heart murmurs or pericardial effusion, hepatosplenomegaly, lymphadenopathy, and varying degrees of edema or pleural ascites.
III. Auxiliary Examinations
(1) Urinalysis may reveal varying degrees of proteinuria, microscopic hematuria, leukocytes, red blood cells, and casts.
(2) Most patients have grade II anemia, occasionally presenting as hemolytic anemia. Decreased white blood cell count is common, and platelets are often below 100×109/L. Erythrocyte sedimentation rate (ESR) is typically elevated.
(3) Immunological tests: Serum shows positivity for multiple autoantibodies, significantly elevated γ-globulin, positive circulating immune complexes, and hypocomplementemia, especially during active disease. Positive lupus erythematosus (LE) cells and positive lupus band test on skin biopsy.
(4) Severe active lupus nephritis may present with reversible declines in Ccr, elevated blood urea nitrogen (BUN) and creatinine, decreased serum albumin, or elevated liver transaminases. End-stage lupus nephritis shows significant declines in Ccr and marked increases in serum creatinine and BUN.
(5) Imaging studies: Ultrasound may show bilateral kidney enlargement, suggesting acute sexually transmitted disease changes. Some patients may have hepatosplenomegaly or pericarditis.(6) Renal biopsy helps determine the pathological type, disease activity, and treatment plan. For systemic lupus erythematosus (SLE) with renal involvement as the initial manifestation, renal biopsy aids in definitive diagnosis.
IV. Differential Diagnosis
For cases presenting with nephrotic syndrome but no obvious SLE manifestations, primary nephrotic syndrome should be ruled out. Cases with pulmonary hemorrhage should be differentiated from Goodpasture syndrome and small vessel vasculitis.
bubble_chart Treatment Measures
1. The treatment of lupus nephritis is based on clinical manifestations, laboratory findings, and renal biopsy data. For mild systemic lupus erythematosus
(e.g., only presenting with rash, low-grade fever, or joint symptoms) and abnormal immunoserological tests, if urinalysis is normal and renal biopsy shows normal or minor glomerular lesions, nonsteroidal anti-inflammatory drugs may be used as appropriate to alleviate symptoms. Generally, glucocorticoids or cytotoxic drugs are not required, but close monitoring of disease progression is necessary. If urinalysis is abnormal and renal biopsy reveals focal segmental mesangial proliferation with segmental necrosis, crescent formation, and focal glomerulosclerosis, moderate to low-dose glucocorticoids (e.g., prednisone 20–40 mg/day) should be used, with cytotoxic drugs or Root Leaf or Flower of Common Threewingnut preparations added as appropriate.
2. For severe systemic lupus erythematosus (e.g., high fever, arthralgia, weakness, and/or rapid involvement of serous membranes, heart, lungs, liver, hematopoietic organs, and other tissues) accompanied by acute nephritic syndrome or rapidly progressive nephritic syndrome, renal biopsy showing diffuse proliferative glomerulonephritis or crescentic glomerulonephritis, and progressive renal function decline, standard hormone therapy plus CTX pulse therapy should be administered. Alternatively, methylprednisolone pulse therapy (1.0 g/day intravenously for 3–5 days per course) may be used, followed by moderate-dose prednisone maintenance. If necessary, the pulse therapy may be repeated after 7–10 days, generally not exceeding three courses. If the above methods are ineffective or the condition is severe, plasma exchange therapy may be considered. For patients who cannot tolerate CTX, cyclosporine A or mycophenolate mofetil may be tried. In cases of acute severe renal insufficiency, severe hypervolemia, or heart failure, emergency dialysis should be performed to stabilize the patient, creating conditions and buying time for drug therapy.
4. For patients presenting with nephrotic syndrome but minimal urinary red blood cells, stable renal function, or renal biopsy showing membranous lupus
nephritis, prednisone (0.8–1.0 mg/kg/day) should be the first-line treatment. If the response is inadequate after 2–4 weeks, CTX should be added. If accompanied by declining renal function, severe hypertension, or renal biopsy showing significant glomerular proliferation or pathological transformation, standard hormone therapy plus CTX pulse therapy should be administered.
5. For persistent proteinuria without systemic lupus erythematosus manifestations or azotemia with renal pathology dominated by
chronic sexually transmitted disease changes, long-term treatment with prednisone and cytotoxic drugs is generally not recommended.
6. End-stage lupus nephritis should be managed as chronic kidney failure.
7. General treatment includes rest, diet, diuresis, blood pressure control, anticoagulation, and prevention of complications, which should be tailored to the patient’s condition with reference to the treatment of primary glomerular diseases.
8. Traditional Chinese medicine (TCM) treatment based on pattern identification can improve efficacy, reduce symptoms, and mitigate the side effects of Western medicine.
