eMedicine Specialties > Rheumatology > Systemic Rheumatic Disease

Nephritis, Lupus: Follow-up

Author: Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Coauthor(s): Fadi Ahmad Hamed, MD, Resident Physician, Department of Internal Medicine, Albert Einstein Medical Center
Contributor Information and Disclosures

Updated: Jun 23, 2009

Follow-up

Further Outpatient Care

  • Follow-up visits
    • Schedule the patient for close follow-up after the initiation of therapy, especially those with focal lupus nephritis, diffuse lupus nephritis, or membranous lupus nephritis, to monitor therapy response and treatment-related toxicities.
    • Upon initiation of high-dose corticosteroids, cyclophosphamide, azathioprine, or mycophenolate mofetil, arrange for the patient to visit a physician at least every month.
  • Follow-up testing
    • Use the ESR, anti-dsDNA, and C3 and C4 to monitor systemic lupus erythematosus (SLE) disease activity.
    • Cyclophosphamide therapy requires regular laboratory monitoring, including CBC count and urinalysis.
    • Azathioprine and mycophenolate mofetil therapy requires regular monitoring of CBC count and less-frequent monitoring of liver function.
  • Determine renal function, urinalysis results, and albumin levels monthly and check spot urine for creatinine and protein or determine creatinine clearance and 24-hour urinary protein excretion every 3 months. After the initiation of therapy and as the patient's condition stabilizes, monitoring may be less frequent.
  • Exercise vigilance with flares of lupus nephritis, even in patients who are stable for many months or years.

Complications

  • Disease-related complications may be secondary to hypertension and nephrotic syndrome and include the following:
    • Cardiovascular complications
    • Stroke
    • Hyperlipidemia
    • Hypercoagulability with thrombosis
  • Treatment-related complications include the following:
    • Infections
    • Cytopenias
    • Bladder toxicity
    • Infertility
    • Premature gonadal failure
    • Osteoporosis
    • Avascular necrosis
    • Premature atherosclerosis
    • Small increased risk of malignancy

Prognosis

  • Poor prognostic indicators4,46
    • Delay in treatment of more than 5 months from onset of nephritis
    • Young age at onset of nephritis
    • Male sex
    • Black racial background
    • Hypertension
    • Nephrotic syndrome
    • Elevated creatinine level (>3 mg/dL) at presentation
    • Persistently elevated anti-dsDNA and low C3 and C4 levels
    • Renal biopsy findings showing diffuse lupus nephritis or high chronicity index
  • Excellent prognosis: Minimal mesangial lupus nephritis and mesangial proliferative lupus nephritis (ISN/RPS 2003 classes I and II) carry an excellent prognosis.
  • Good prognosis: Focal lupus nephritis (ISN/RPS 2003 class III) carries a good prognosis, with only a minority of patients developing progressive renal failure.
  • Fair prognosis
    • Diffuse lupus nephritis (ISN/RPS 2003 class IV) carries a fair prognosis, with a significant number of patients developing progressive renal failure.
    • Membranous lupus nephritis (ISN/RPS 2003 class V) carries a fair prognosis, with a significant number of patients developing progressive renal deterioration gradually over time.
  • Poor prognosis: Advanced sclerosis lupus nephritis (ISN/RPS 2003 class VI) carries a poor prognosis.

Patient Education

  • Educate the patient about the serious nature of lupus nephritis, various therapies, and potential toxicities of treatment.
  • The patient must understand signs of treatment-related toxicities, such as infection and bladder toxicity, so an immediate evaluation can be initiated.
  • These patients must also understand the risks for atherosclerotic and thrombotic events, even in young women, and that any signs or symptoms that suggest such an event warrant an immediate evaluation.
  • For excellent patient education resources, visit eMedicine's Diabetes Center, Blood and Lymphatic System Center, and Arthritis Center. Also, see eMedicine's patient education articles Chronic Kidney Disease and Lupus (Systemic Lupus Erythematosus).

Miscellaneous

Medicolegal Pitfalls

  • Before instituting therapy for lupus nephritis, performing a renal biopsy is generally recommended to confirm the diagnosis and to determine the type of histology as a guide to appropriate therapy. The risk of renal biopsy must be clearly explained. If the patient refuses renal biopsy, the patient must understand how this can limit diagnostic accuracy.
  • Because the therapy for lupus nephritis has significant potential for toxicity, the potential adverse effects of corticosteroids and immunosuppressive agents must be discussed. The risks of withholding therapy must also be discussed.

Special Concerns

  • Pediatric lupus nephritis
    • Children with SLE are at a higher risk of renal disease than adults and tend to sustain more disease damage secondary to more aggressive disease and treatment-associated toxicity.5,6 Renal biopsy findings associated with pediatric lupus nephritis show a higher rate of focal and diffuse lupus nephritis compared with findings associated with adult lupus nephritis, and the prevalence of progression to renal failure is increased. Renal involvement occurs in two thirds of children and adolescents with SLE. Since the advent of immunosuppressive therapy, survival rates have improved; however, this improvement has occurred at the expense of long-term morbidity and complications of therapy, with profound consequences. Bogdanovic et al (2004) found a 5-year survival rate of 98% and a renal survival rate of 89% (without end-stage renal disease) in children with lupus nephritis.47
    • In the treatment of patients with pediatric lupus nephritis, early therapy to control the disease should be balanced with long-term follow-up to minimize the adverse effects of therapy and the disease complications. Poor prognostic features include a renal biopsy specimen that shows diffuse lupus nephritis, persistent hypertension, persistent elevated anti-dsDNA, and hypocomplementemia.
  • Pregnancy and lupus nephritis48,49,50
    • Patients with SLE should avoid pregnancy because it may aggravate renal disease, especially in the presence of active lupus nephritis, nephrotic syndrome, severe hypertension, or serum creatinine levels elevated to more than 2 mg/dL.
    • Patients with lupus nephritis have a 50-60% chance of renal flare during pregnancy if they conceive during active disease.
    • Patients with well-controlled SLE who conceive after a 3- to 6-month period of remission have a 7-10% chance of renal flare.
    • Pregnant patients with lupus nephritis are prone to preeclampsia. Preexisting hypertension and antiphospholipid antibody syndrome are the two most common factors that predispose to preeclampsia.
    • Severe flares during pregnancy may cause acute renal failure and maternal and fetal death. Closely monitor pregnant patients with SLE, aggressively treat exacerbations, and carefully avoid administering teratogenic drugs.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Irene Viola, MD, to the development and writing of this article.



More on Nephritis, Lupus

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Differential Diagnoses & Workup: Nephritis, Lupus
Treatment & Medication: Nephritis, Lupus
Follow-up: Nephritis, Lupus
Multimedia: Nephritis, Lupus
References
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References

  1. D'Agati VD, Appel GB. Lupus Nephritis: Pathology and Pathogenesis. In: Wallace DJ, Hahn BH, eds. Dubois' Lupus Erythematosus. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:1094-111.

  2. Grande JP. Mechanisms of progression of renal damage in lupus nephritis: pathogenesis of renal scarring. Lupus. 1998;7(9):604-10. [Medline].

  3. Rus V, Maury EE, Hochberg MC. Epidemiology of Systemic Lupus Erythematosus. In: Wallace DJ, Hahn BH, eds. Dubois' Lupus Erythematosus. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:34-44.

  4. Dooley MA. Clinical and laboratory features of lupus nephritis. In: Wallace DJ, Hahn BH, eds. Dubois' Lupus Erythematosus. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:1112-30.

  5. Gloor JM. Lupus nephritis in children. Lupus. 1998;7(9):639-43. [Medline].

  6. Brunner HI, Gladman DD, Ibañez D, Urowitz MD, Silverman ED. Difference in disease features between childhood-onset and adult-onset systemic lupus erythematosus. Arthritis Rheum. Feb 2008;58(2):556-62. [Medline].

  7. Pisetsky DS, Gilkeson G, St. Clair EW. Systemic lupus erythematosus. Diagnosis and treatment. Med Clin North Am. Jan 1997;81(1):113-28. [Medline].

  8. Tsao BP. Update on human systemic lupus erythematosus genetics. Curr Opin Rheumatol. Sep 2004;16(5):513-21. [Medline].

  9. Nath SK, Kilpatrick J, Harley JB. Genetics of human systemic lupus erythematosus: the emerging picture. Curr Opin Immunol. Dec 2004;16(6):794-800. [Medline].

  10. Wong M, Tsao BP. Current topics in human SLE genetics. Springer Semin Immunopathol. Oct 2006;28(2):97-107. [Medline].

  11. Harley JB, Kelly JA, Kaufman KM. Unraveling the genetics of systemic lupus erythematosus. Springer Semin Immunopathol. Oct 2006;28(2):119-30. [Medline].

  12. Harley JB, Alarcón-Riquelme ME, Criswell LA, Jacob CO, Kimberly RP, Moser KL, et al. Genome-wide association scan in women with systemic lupus erythematosus identifies susceptibility variants in ITGAM, PXK, KIAA1542 and other loci. Nat Genet. Feb 2008;40(2):204-10. [Medline].

  13. Crow MK. Collaboration, genetic associations, and lupus erythematosus. N Engl J Med. Feb 28 2008;358(9):956-61. [Medline].

  14. Rahman A, Isenberg DA. Systemic lupus erythematosus. N Engl J Med. Feb 28 2008;358(9):929-39. [Medline].

  15. Mohan C, Adams S, Stanik V, Datta SK. Nucleosome: a major immunogen for pathogenic autoantibody-inducing T cells of lupus. J Exp Med. May 1 1993;177(5):1367-81. [Medline].

  16. Muller S, Dieker J, Tincani A, Meroni PL. Pathogenic anti-nucleosome antibodies. Lupus. 2008;17(5):431-6. [Medline].

  17. Crow MK. Interferon pathway activation in systemic lupus erythematosus. Curr Rheumatol Rep. Dec 2005;7(6):463-8. [Medline].

  18. Rönnblom L, Eloranta ML, Alm GV. The type I interferon system in systemic lupus erythematosus. Arthritis Rheum. Feb 2006;54(2):408-20. [Medline].

  19. Rönnblom L, Pascual V. The innate immune system in SLE: type I interferons and dendritic cells. Lupus. 2008;17(5):394-9. [Medline].

  20. Arbuckle MR, McClain MT, Rubertone MV, et al. Development of autoantibodies before the clinical onset of systemic lupus erythematosus. N Engl J Med. Oct 16 2003;349(16):1526-33. [Medline].

  21. Yung S, Chan TM. Anti-DNA antibodies in the pathogenesis of lupus nephritis--the emerging mechanisms. Autoimmun Rev. Feb 2008;7(4):317-21. [Medline].

  22. Simón JA, Cabiedes J, Ortiz E, Alcocer-Varela J, Sánchez-Guerrero J. Anti-nucleosome antibodies in patients with systemic lupus erythematosus of recent onset. Potential utility as a diagnostic tool and disease activity marker. Rheumatology (Oxford). Feb 2004;43(2):220-4. [Medline].

  23. Su Y, Jia RL, Han L, Li ZG. Role of anti-nucleosome antibody in the diagnosis of systemic lupus erythematosus. Clin Immunol. Jan 2007;122(1):115-20. [Medline].

  24. Bigler C, Lopez-Trascasa M, Potlukova E, Moll S, Danner D, Schaller M, et al. Antinucleosome antibodies as a marker of active proliferative lupus nephritis. Am J Kidney Dis. Apr 2008;51(4):624-9. [Medline].

  25. Marto N, Bertolaccini ML, Calabuig E, Hughes GR, Khamashta MA. Anti-C1q antibodies in nephritis: correlation between titres and renal disease activity and positive predictive value in systemic lupus erythematosus. Ann Rheum Dis. Mar 2005;64(3):444-8. [Medline].

  26. Sinico RA, Radice A, Ikehata M, Giammarresi G, Corace C, Arrigo G, et al. Anti-C1q autoantibodies in lupus nephritis: prevalence and clinical significance. Ann N Y Acad Sci. Jun 2005;1050:193-200. [Medline].

  27. Grande JP, Balow JE. Renal biopsy in lupus nephritis. Lupus. 1998;7(9):611-7. [Medline].

  28. Weening JJ, D'Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol. Feb 2004;15(2):241-50. [Medline].

  29. Houssiau FA, Ginzler EM. Current treatment of lupus nephritis. Lupus. 2008;17(5):426-30. [Medline].

  30. Dooley MA, Falk RJ. Immunosuppressive therapy of lupus nephritis. Lupus. 1998;7(9):630-4. [Medline].

  31. Dooley MA, Ginzler EM. Newer therapeutic approaches for systemic lupus erythematosus: immunosuppressive agents. Rheum Dis Clin North Am. Feb 2006;32(1):91-102, ix. [Medline].

  32. Chan TM, Li FK, Tang CS, et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. Hong Kong-Guangzhou Nephrology Study Group. N Engl J Med. Oct 19 2000;343(16):1156-62. [Medline].

  33. Ginzler EM, Dooley MA, Aranow C, Kim MY, Buyon J, Merrill JT. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med. Nov 24 2005;353(21):2219-28. [Medline].

  34. Contreras G, Pardo V, Leclercq B, et al. Sequential therapies for proliferative lupus nephritis. N Engl J Med. Mar 4 2004;350(10):971-80. [Medline].

  35. [Best Evidence] Appel GB, Contreras G, Dooley MA, Ginzler EM, Isenberg D, Jayne D, et al. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis. J Am Soc Nephrol. May 2009;20(5):1103-12. [Medline].

  36. Gourley MF, Austin HA 3rd, Scott D, et al. Methylprednisolone and cyclophosphamide, alone or in combination, in patients with lupus nephritis. A randomized, controlled trial. Ann Intern Med. Oct 1 1996;125(7):549-57. [Medline].

  37. Ciruelo E, de la Cruz J, Lopez I, Gomez-Reino JJ. Cumulative rate of relapse of lupus nephritis after successful treatment with cyclophosphamide. Arthritis Rheum. Dec 1996;39(12):2028-34. [Medline].

  38. Somers EC, Marder W, Christman GM, Ognenovski V, McCune WJ. Use of a gonadotropin-releasing hormone analog for protection against premature ovarian failure during cyclophosphamide therapy in women with severe lupus. Arthritis Rheum. Sep 2005;52(9):2761-7. [Medline].

  39. Silverman GJ. Anti-CD20 therapy in systemic lupus erythematosus: a step closer to the clinic. Arthritis Rheum. Feb 2005;52(2):371-7. [Medline].

  40. Looney RJ, Anolik JH, Campbell D, Felgar RE, Young F, Arend LJ. B cell depletion as a novel treatment for systemic lupus erythematosus: a phase I/II dose-escalation trial of rituximab. Arthritis Rheum. Aug 2004;50(8):2580-9. [Medline].

  41. Leandro MJ, Cambridge G, Edwards JC, Ehrenstein MR, Isenberg DA. B-cell depletion in the treatment of patients with systemic lupus erythematosus: a longitudinal analysis of 24 patients. Rheumatology (Oxford). Dec 2005;44(12):1542-5. [Medline].

  42. Ng KP, Leandro MJ, Edwards JC, Ehrenstein MR, Cambridge G, Isenberg DA. Repeated B cell depletion in treatment of refractory systemic lupus erythematosus. Ann Rheum Dis. Jul 2006;65(7):942-5. [Medline].

  43. Looney RJ, Anolik J, Sanz I. New therapies for systemic lupus erythematosus: cellular targets. Rheum Dis Clin North Am. Feb 2006;32(1):201-15, xi. [Medline].

  44. Furie R. Abetimus sodium (riquent) for the prevention of nephritic flares in patients with systemic lupus erythematosus. Rheum Dis Clin North Am. Feb 2006;32(1):149-56, x. [Medline].

  45. Kirou KA, Salmon JE, Crow MK. Soluble mediators as therapeutic targets in systemic lupus erythematosus: cytokines, immunoglobulin receptors, and the complement system. Rheum Dis Clin North Am. Feb 2006;32(1):103-19, ix. [Medline].

  46. Ponticelli C, Moroni G. Flares in lupus nephritis: incidence, impact on renal survival and management. Lupus. 1998;7(9):635-8. [Medline].

  47. Bogdanovic R, Nikolic V, Pasic S, Dimitrijevic J, Lipkovska-Markovic J, Eric-Marinkovic J. Lupus nephritis in childhood: a review of 53 patients followed at a single center. Pediatr Nephrol. Jan 2004;19(1):36-44. [Medline].

  48. Khamashta MA. Systemic lupus erythematosus and pregnancy. Best Pract Res Clin Rheumatol. Aug 2006;20(4):685-94. [Medline].

  49. Petri M. The Hopkins Lupus Pregnancy Center: ten key issues in management. Rheum Dis Clin North Am. May 2007;33(2):227-35, v. [Medline].

  50. Witter FR. Management of the high-risk lupus pregnant patient. Rheum Dis Clin North Am. May 2007;33(2):253-65, v-vi. [Medline].

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Further Reading

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Keywords

lupus nephritis, systemic lupus erythematosus, SLE, end-stage renal disease, ESRD, end-stage kidney disease, chronic kidney disease, chronic renal disease, chronic renal failure, glomerulonephritis, hematuria, renal failure, kidney failure, mesangial nephritis, hypertension, proteinuria, active lupus nephritis, focal proliferative lupus nephritis, diffuse proliferative lupus nephritis, mesangial lupus nephritis, membranous lupus nephritis, active nephritis, sclerosing lupus nephritis, mesangial proliferative lupus nephritis, focal lupus nephritis, diffuse lupus nephritis, focal sclerosing lupus nephritis, diffuse segmental proliferative lupus nephritis, diffuse global proliferative lupus nephritis, diffuse segmental sclerosing lupus nephritis, diffuse global sclerosing lupus nephritis, advanced sclerosis lupus nephritis

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Contributor Information and Disclosures

Author

Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

Coauthor(s)

Fadi Ahmad Hamed, MD, Resident Physician, Department of Internal Medicine, Albert Einstein Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Carlos J Lozada, MD, Director of Rheumatology Fellowship Program, Associate Professor, Department of Medicine, Division of Rheumatology and Immunology, Jackson Memorial Medical Center, University of Miami School of Medicine
Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ajay K Singh, MB, MRCP, MBA, Associate Professor of Medicine, Harvard Medical School; Clinical Chief, Renal Division, Director of Dialysis, Brigham and Women's Hospital; Consulting Staff, Faulkner Hospital
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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