A 33-year-old woman comes in for a follow-up appointment. She was seen 6 months ago for a rash on her face, profound fatigue, and arthritis. The patient was diagnosed with systemic lupus erythematosus and started on hydroxychloroquine and low-dose prednisone. She has experienced marked improvement in her symptoms and has resumed her usual activities.
Physical examination shows a faint facial rash but is otherwise unremarkable.
Current laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Question

A 33-year-old woman comes in for a follow-up appointment.  She was seen 6 months ago for a rash on her face, profound fatigue, and arthritis.  The patient was diagnosed with systemic lupus erythematosus and started on hydroxychloroquine and low-dose prednisone.  She has experienced marked improvement in her symptoms and has resumed her usual activities.
Physical examination shows a faint facial rash but is otherwise unremarkable.
Current laboratory results are as follows:

Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Over half of all patients with systemic lupus erythematosus (SLE) will develop renal disease during their lifetime, an important indicator of overall prognosis. Anti-double-stranded DNA antibodies have been implicated in the pathogenesis of lupus nephritis (LN), although they are not always detectable in the serum. In addition, while standard laboratory tests can suggest the type of renal involvement, multiple classes of LN can have overlapping patterns and the results may not reflect the extent of disease. A renal biopsy is needed to accurately distinguish among the various subtypes of LN. subtypes of LN Renal biopsy should be performed when any new evidence of kidney involvement is present, including proteinuria (>500 mg/day), elevated creatinine, or active urine sediment. Mild proteinuria alone does not require aggressive immunosuppressive therapy, and biopsy may not be necessary. Repeat biopsies should be performed with evidence of new or worsening laboratory markers as transformation of LN subtypes can occur. (Choice A) Radiologic imaging has little role in the evaluation of LN, although renal ultrasonography and noncontrast CT scans can be used in acute kidney injury to rule out other suspected causes, such as obstruction or nephrolithiasis. (Choices B and D) Hydroxychloroquine, with or without glucocorticoids, is appropriate for mild SLE without nephritis. However, additional immunosuppressive therapy is likely needed in this patient. The particular regimen is determined by the specific LN subtype, which is based on renal biopsy findings. (Choice E) Urine protein electrophoresis may demonstrate polyclonal gammopathy in LN but would not be helpful in distinguishing the LN subtype. Serum protein electrophoresis is unlikely to be helpful. Educational objective: Over half of all patients with systemic lupus erythematosus will develop renal disease during their lifetime. A renal biopsy should be performed when any new evidence of kidney involvement, including proteinuria, elevated creatinine, or active urine sediment, is present. __________ References: Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. (http://www.ncbi.nlm.nih.gov/pubmed/22851469) The kidney biopsy in lupus nephritis: is it still relevant? (http://www.ncbi.nlm.nih.gov/pubmed/25034161)

A 33-Year-Old Woman Comes in for a Follow-Up Appointment