Test Your Knowledge: Managing Lupus Nephritis

AUTHOR:
Abdallah S. Geara, MD
Assistant Professor of Clinical Medicine, University of Pennsylvania

CITATION:
Geara AS. Test your knowledge: managing lupus nephritis. Consultant360. Published online June 29, 2021.

A 32-year-old woman with class III lupus nephritis has been in partial remission with mycophenolate mofetil, 1000 mg, twice daily for the past 2 years. During the COVID-19 pandemic, she had stopped all her medications, which led to the development of nephrotic syndrome and poorly controlled hypertension.

The patient was started on torsemide and spironolactone for diuresis, as well as diltiazem and lisinopril for treating the hypertension. After extensive counseling regarding her treatment options, the patient was started on intravenous cyclophosphamide, 500 mg, every 2 weeks and a steroid taper.

At week 6—during her third infusion—the patient’s edema had improved, but her blood pressure (BP) was still poorly controlled, with most of her home BP measurements in the 150/90 to 159/99 mm Hg range.

Results of laboratory tests showed a stable creatinine level of 0.8 mg/dL since lupus nephritis was diagnosed 2 years prior, an improved serum albumin level of 2.9 g/dL at week 0 to 3.2 g/dL at week 6, and an improved urine protein to creatinine ratio from 4.0 g/g of creatinine at week 0 to 2.6 g/g of creatinine at week 6.

The patient was discouraged by the partial improvement of proteinuria and was hoping to discuss options to achieve complete remission very quickly.