Lupus Nephritis

 

Ms. Justin Jeya Amutha

Asst. Professor, Sacred Heart Nursing College, Madurai.

*Corresponding Author E-mail: ammulj@gmail.com.

 

ABSTRACT:

Kidneys are the most important excretory organs within the human body. The word excretion means the removal of metabolic waste substances from the body. This "metabolic waste" is the large number of chemical reactions that occur in the cells, tissues and organs. Of these substances, some of the by-products and end-products of metabolism are toxic and have to be removed from the body, before they will poison the body tissues. The nephron is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine. In humans, a normal kidney contains 800000 to1.5 million nephrons.

 

KEY WORDS: Lupus, Nephritis, Systemic lupus erythematosus.

 

 


INTRODUCTION:

Lupus nephritis is a major cause of morbidity and mortality in patients with systemic lupus erythematosus. The general consensus is that 60% of lupus patients will develop clinically relevant nephritis at some time in the course of their illness. Prompt treatment is important, as early response to therapy is correlated with better outcome.

 

Epidemiology of lupus nephritis:

Most SLE patients develop nephritis early in the course of their disease. The vast majority of patients who develop nephritis are younger than 55years, and children are more likely to develop severe nephritis than are elderly patients. In a recent retrospective study, male sex, young age (<33 years), and non-European ancestry were found to be determinants of earlier renal disease in patients with SLE. Asian, African Caribbean, and African American ethnicities may present with more severe nephritis than other ethnic groups.

 

What are the kidneys and what do they do?

The kidneys are two bean shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, with one located on either side of the supine. Every day, and the two kidneys process about 200 quarts of blood to produce about 1 to 2 quarts of urine, which is made up of waste and extra water. The urine flows from the kidneys to the bladder through tubes called ureter. The bladder stores urine until releasing it through urination. Kidney failure is a condition where the filtering units (glomeruli) inside of the kidneys become damaged and are unable to filter out the waste and toxins then remain in the blood stream causing complications throughout the body. These complications can hinder the function of vital organs making a person become very ill.

 

Lupus:

Lupus is a lifelong disorder of the immune system .Immune cells attack the body’s own healthy tissues, leading to inflammation and tissue damage.

 

Nephritis:

Inflammation of the nephron.

 

Lupus nephritis:

Lupus nephritis is inflammation of the kidney that is caused by systemic lupus erythematous (SLE).SLE is an auto immune disease. With lupus, the body’s immune system targets its own body tissues. Lupus nephritis happens when lupus involves the kidneys

 

Stages :

Stage 1:

There is no evidence of lupus nephritis

 

Stage 2:

Mildest form, and it’s easily treated with corticosteroids

 

Stage 3:

Earliest stage of advanced lupus. Treatment requires high amounts of corticosteroids

 

Stage 4:

Advanced stage of lupus. There is a risk of kidney failure. people with lupus nephritis in this stage require high amounts of corticosteroids and immune suppression medications.

 

Stage 5:

Involves excessive protein loss and swelling. Treat this type of patients with high amounts of corticosteroids They may or may not give drugs that suppress immune system.

 

Symptoms:

·         Foamy urine

·         Blood in the urine

·         Pain in mid-back or flank

·         Swelling

·         Dark urine

·         High blood pressure

·         Changes in frequency of urination

·         Vomiting

·         Water retention / weight gain

·         They are often prone to urinary tract infections

 

Clinical findings of this patient:

The patient had the problem of severe flank pain, episodes of vomiting, problem in urination, swelling especially in the extremities and increased weight also.

 

Diagnostic Evaluation:

The diagnosis will then be confirmed through imaging tests, urine and blood tests and kidney biopsy

 

Investigation /Book picture

Patient picture

Urinalysis :

Increased  RBC

Increased protein in urine

 

Iothalamate clearance testing

Blood test

 

 

 

 

 

 

Kidney biopsy

 

Ultrasound

 

Increased   RBC

Urine Protein- 749.8mg/dl

Urine spot PCR-9.6

 

Urea           -134 mg/dl

Creatinine - 4.20mg/dl

 

Serum lipase    -282.0u/l

ANA (Anti nuclear antibody) – strong positive

ElISA IgG – 9.9(positive)

 

Left renal biopsy was done

 

Management:

·         The goals of treatment are to reduce inflammation, return clinical and laboratory values to normal and prevent further kidney damage.

·         Treatment is difficult but patients who have right treatment can see positive results so early detection is important.

 

Pharmacological:

·         Immune suppressive :

These are medications that suppress the immune system, so it stops attacking and damaging the kidneys. These medications include

·         cyclophosphamide (Cytoxan )

·         azathioprine  (Imuran )

·          mycophenolate  (Cellcept)

 

·         Corticosteroids:

These are very strong anti-inflammatory drugs that decrease the inflammation in kidneys.

·         Prednisone

 

·         Medications that lower blood pressure:

·         Angiotensin converting enzyme inhibitor (ACE)

·         Angiotensin receptor blockers (ARBs)

·         Prevent blood clots may also be prescribed if needed.

These have proven effective in helping slow kidney disease progression.

 

·         Hydroxychloroquine  (plaque nil):

This is a common medication for treating SLE .This should also be prescribed for people with lupus nephritis

 

·         Diuretics:

These medications, that help the kidneys remove fluid from the body, may also be prescribed. If both of the kidneys fail, the patient may need dialysis this is the procedure that filters blood through a machine in order to remove waste products from the body. In the most severe cases, a kidney transplant may eventually be necessary.

 

Life style changes:

·         Stay well hydrated by drinking enough fluids:

According to the mayo clinic, The Institute of Medicine determined that an adequate intake for men is roughly 3litres (about 13cups) of total beverages a day. The adequate intake for women is 2.2litres (about 9cups) of total beverages a day.

 

·         Maintain a healthy blood pressure:

120/80 is generally considered to be in healthy range.

 

·         Exercise regularly:

30 minutes at least three times per week can make a positive impact on overall health

 

·         Limit intake of cholesterol:

The American Heart Association recommends that the person limit average daily cholesterol intake to less than 300 milligrams.

 

·         Avoid NSAIDs:

Avoid non-steroidal anti-inflammatory drugs as these can affect the kidneys, such as ibuprofen, aspirin or Naproxen.

 

·         Eat a low sodium diet:

Eat a low sodium diet especially if the person has high blood pressure.

 

COMPLICATIONS:

The most serious complication associated with lupus nephritis is kidney failure.

 

CONCLUSION:

The above report demonstrates the importance of considering the presence of a coexisting autoimmune disease in a patient with sickle hemo globinopathy who displays an atypical and multisystem presentation that is unresponsive to conventional therapies. The presence of SLE-specific antibodies and hypocomplementemia can be especially helpful in substantiating a diagnosis of lupus. Finally, when significant kidney disease is present, a renal biopsy is critical in establishing the correct diagnosis. Identifying the etiology of a renal abnormality in the setting of existing SLE is important, because there are different implications for morbidity, mortality, and therapeutic options.

 

REFERENCE:

1.        Churg. J.et al (2000) Renal Disease: Classification and Atlas of Glomerular Diseases, Igaky-Shoin, New York, 2nd edition: pp 366-3671.

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6.        Najafi. C. C et al, (2001) “Significance of histologic patterns of glomerular injury upon long-term prognosis in severe lupus glomerulonephritis,”, vol. 59, no. 6, pp. 2156–2163.

7.        Pollak.V. E.(2001), “The natural history of the renal manifestations of systemic lupus erythematosus,” The Journal of Laboratory and Clinical Medicine, vol. 63, no. 4, pp. 537–550.

8.        Pirani. C. L,(1998) “Role of electron microscopy in the classification of lupus nephritis,” in Advances in Systemic Lupus Erythematosus, pp. 54–87, Grune and Stratton, New York .

9.        Weening. J.J et al.,(2004) “International Society of Nephrology

10.     Working Group on the Classification of Lupus Nephritis; Renal Pathology Society Working Group on the Classification of Lupus Nephritis. The classification of glomerulonephritis in systemic lupus erythematosus revisited, vol. 65, pp. 521–530.

 

 

 

Received on 01.09.2016          Modified on 21.12.2016

Accepted on 28.02.2017          © A&V Publications all right reserved

Int. J. Adv. Nur. Management. 2017; 5(2):169-171. 

DOI: 10.5958/2454-2652.2017.00036.1