Upto 90% have pathological evidence but only 50% have clinical
evidence
Biopsy is diagnostic
Class III Focal lupus nephritis (<50% glomerulli, sub endothelial deposits)
Class IV Diffuse lupus nephritis( >50% glomeruli involved, Segmental and Global lesions)
IV – S Active & chronic lesions - Diffuse segmental proliferative & sclerosing lupus
(A/C) nephritis
IV – G Active & chronic lesions - Diffuse global proliferative & sclerosing lupus nephritis
(A/C)
IV – S (C) Chronic inactive lesions with scars - Diffuse segmental sclerosing lupus nephritis
IV – G (C) Chronic inactive lesions with scars - Diffuse segmental global lupus nephritis
Valvular Abnormalities-
Valvular thickening with mitral and aortic valve involvement is most common in
60% of patients.
Libman Sacks endocarditis – 43% of patients. pea sized, flat or raised, bland,
granular lesion on ventricular aspect of mitral valve posterior leaflet and vessel
side of aortic valve. Can be active or healed lesions.
Valvular stenosis in 4%
CAD-Atherosclerosis, coronary artery
vasculitis, coronary artery thrombosis
Lupus enteritis affects jejunum and ileum. Ascites is seen in 11% of patients
though peritoneal inflammation is seen in 60% of patients.
50% of SLE have anemia.(ACD>IDA>AIHA)
MAHA should prompt consideration for TTP and HUS(schistocytes).rule out CAPS by APLA
AIHA and isolated thrombocytopenia may precede years before SLE develops
Periarterial fibrosis or ‘onion skin’ lesion in
spleen is pathognomonic of SLE.
Kikuri Fujimoto Disease is a self limited form
of SLE.Presenting as cervical Lnpathy with
tenderness and night sweats, fever.
Lower androgen levels with increased
estrogen levels.
SIADH
Most common is keratoconjunctivitis sicca
Malignancy-particularly NHL
MCTD
SEROLOGICAL TESTS-
ANA(byIF test) is gold standard and present in >95% of patients.
Also positive in RA,scleroderma, polymyositis, autoimmune
thyroiditis, elderly(<1:80)
Negative test rules out SLE
If ANA positive, then determine which particular nuclear antigens
are target
Anti ds DNA is highly specific for SLE but present in 60% of
patients
Anti Sm is also highly specific for SLE but present in 30% of
patients.
Complement consumption leads to hypocomplementemia(rare in
other diseases) and signify active disease
Homogenous-anti dsDNA, speckled-anti RNP, nucleolar-anti
RNA polymerase I/III,cytoplasmic-anti Jo-1
Urinalysis is an effective method to detect and monitor disease
activity in lupus nephritis.
HCQ delays the onset of SLE and reduces the number and severity of clinical flares.
They protect against thrombosis, renal damage, and major infections in SLE.
HCQ is associated with an 80% clinical response rate at 3 months when used in
doses of 5 mg/kg/day for non–organ-threatening disease.
Because HCQ can induce corneal edema and retinal pigmentation (the latter occurs
in 3% of patients who have used the drug for 10 years or longer), it is
recommended that baseline screening should be performed during the first few
months of therapy and again at 5 years followed by annual examinations.
Neuropsychological assessment
Multiple pregnancies
NSAIDs can be used sporadically in the first and second trimesters of pregnancy, but
they are associated with an increased risk of miscarriage and oligohydramnios . NSAIDs
should be avoided in the last trimester of pregnancy due to concerns of premature
closure of the ductus arteriosus and worsening of hypertension.
Arthralgias, myalgias, and backaches are normal symptoms of pregnancy and can
usually be managed conservatively with acetaminophen and physical therapy. True
synovitis does not occur in normal pregnancy and can be related to a lupus flare.
Mild anemia and thrombocytopenia are normal variants of pregnancy, but severe anemia
and thrombocytopenia may be an indication of an immune-mediated process. The
presence of leukopenia and lymphopenia should raise the suspicion of a systemic
autoimmune process.
A rise in C3 and C4 levels is a normal variation of pregnancy and this can make
identifying an SLE flare difficult, so normal complement levels should not automatically
be interpreted as an indication of disease quiescence.
Double-stranded DNA, however is not affected by pregnancy and can increase when
SLE is uncontrolled.
Asymptomatic carriers of antiphospholipid antibodies with no history of pregnancy loss
or thrombosis, treatment is generally not needed.
Women with a history of recurrent thrombosis may need lifelong treatment. Despite the
risks associated with the presence of antiphospholipid antibodies, live births have been
reported in over 50% to 74% of such patients when treatment was initiated.