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1.
Yonsei Med J ; 61(11): 951-957, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33107238

RESUMO

PURPOSE: To compare the clinical characteristics and renal outcomes between patients who initially had lupus nephritis (LN) at the onset of systemic lupus erythematosus (SLE) (initial-onset LN) and those who developed LN within 5 years after SLE onset (early-onset LN). MATERIALS AND METHODS: SLE patients with biopsy-proven LN were retrospectively reviewed. The clinical parameters and renal outcomes were compared between initial-onset and early-onset LN groups. We used Cox regression analysis to estimate risk of worse renal outcomes according to the onset time of LN. RESULTS: Of all 136 LN patients, 92 (67.6%) and 44 (32.4%) patients were classified into the initial-onset and early-onset LN groups, respectively. The initial-onset LN group had higher prevalences of class IV LN (54.3% vs. 34.1%, p=0.027), impaired renal function (34.8% vs. 11.4%, p=0.004), microscopic hematuria (73.9% vs. 54.5%, p=0.024), and higher urine protein/creatinine ratio [4626.1 (2180.0-6788.3) mg/g vs. 2410.0 (1265.0-5168.5) mg/g, p=0.006] at LN diagnosis. Renal relapse (46.3% vs. 25.7%, p=0.039) and progression to chronic kidney disease (CKD) or end-stage renal disease (ESRD) were more common (24.4% vs. 8.3%, p=0.042) in the initial-onset LN group. In Cox regression analysis, the initial-onset LN group had higher risks of renal relapse [adjusted hazard ratio (HR) 3.56, 95% confidence interval (CI) 1.51-8.35, p=0.004] and progression to CKD or ESRD (adjusted HR 4.57, 95% CI 1.03-20.17, p=0.045), compared with the early-onset LN group. CONCLUSION: Patients with LN at SLE onset may have more severe renal presentations and experience worse renal outcomes than those who develop LN within 5 years.


Assuntos
Falência Renal Crônica/etiologia , Rim/fisiopatologia , Lúpus Eritematoso Sistêmico/patologia , Nefrite Lúpica/patologia , Adulto , Biópsia , Progressão da Doença , Feminino , Humanos , Lúpus Eritematoso Sistêmico/terapia , Nefrite Lúpica/complicações , Nefrite Lúpica/terapia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Adulto Jovem
2.
BMC Infect Dis ; 20(1): 538, 2020 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-32703300

RESUMO

BACKGROUND: The risk of life-threatening complications, such as visceral disseminated varicella zoster virus (VZV) infection, is greater in immunosuppressed individuals, such as systemic lupus erythematosus (SLE) patients. CASE PRESENTATION: Here, a case is reported of a Caucasian woman diagnosed with lupus nephritis and anti-phospholipid syndrome, who was subjected to mycophenolate mofetil and high-dose steroid remission-induction therapy. Two months later she developed abdominal pain followed by a fatal rapid multi-organ failure. As no typical skin rashes were evident, death was initially attributed to catastrophic anti-phospholipid syndrome. However, autopsy and virological examinations on archival material revealed a disseminated VZV infection. CONCLUSIONS: Overall, this case highlights the importance of having a high clinical suspicion of fatal VZV infections in heavily immunosuppressed SLE patients even when typical signs and symptoms are lacking.


Assuntos
Síndrome Antifosfolipídica/complicações , Síndrome Antifosfolipídica/diagnóstico , Herpes Zoster/complicações , Herpes Zoster/diagnóstico , Herpesvirus Humano 3/genética , Nefrite Lúpica/complicações , Nefrite Lúpica/diagnóstico , Dor Abdominal , Evolução Fatal , Feminino , Herpes Zoster/patologia , Herpes Zoster/virologia , Herpesvirus Humano 3/isolamento & purificação , Humanos , Hospedeiro Imunocomprometido , Nefrite Lúpica/tratamento farmacológico , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Reação em Cadeia da Polimerase em Tempo Real , Esteroides/uso terapêutico
3.
Ann Rheum Dis ; 79(8): 1077-1083, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32503858

RESUMO

OBJECTIVES: Short-term predictive endpoints of chronic kidney disease (CKD) are needed in lupus nephritis (LN). We tested response to therapy at 1 year. METHODS: We considered patients with LN who underwent renal biopsy followed by induction therapy between January 1970 and December 2016. LN was assessed using the International Society of Nephrology/Renal Pathology Society (2003) criteria and the National Institute of Health (NIH) activity and chronicity index. The renal outcome was CKD. Response was defined according to EULAR/European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations: complete: proteinuria <0.5 g/24 hours, (near) normal estimated glomerular filtration rate (eGFR); partial: ≥50% proteinuria reduction to subnephrotic levels, (near) normal eGFR; and no response: all the other cases. Logistic regression analysis was employed for 12-month response and Cox regression for CKD prediction. RESULTS: We studied 381 patients (90.5% Caucasians). After 12-month therapy, 58%, 26% and 16% of patients achieved complete, partial and no response, respectively, according to EULAR/ERA-EDTA. During a median follow-up of 10.7 (IQR: 4.97-18.80) years, 53 patients developed CKD. At 15 years, CKD-free survival rate was 95.2%, 87.6% and 55.4% in patients with complete, partial and no response at 12 months, respectively (p<0.0001). CKD-free survival rates did not differ between complete and partial responders (p=0.067). Serum creatinine (HR: 1.485, 95% CI 1.276 to 1.625), eGFR (HR 0.967, 95% CI 0.957 to 0.977) and proteinuria at 12 months (HR 1.234, 95% CI 1.111 to 1.379) were associated with CKD, yet no reliable cut-offs were identified on the receiver operating characteristic curve. In multivariable analysis, no EULAR/ERA-EDTA response at 12 months (HR 5.165, 95% CI 2.770 to 7.628), low C4 (HR 1.053, 95% CI 1.019 to 1.089) and persistent arterial hypertension (HR 3.154, 95% CI 1.500 to 4.547) independently predicted CKD. CONCLUSIONS: Lack of EULAR/ERA-EDTA response at 12 months predicts CKD.


Assuntos
Nefrite Lúpica/complicações , Nefrite Lúpica/tratamento farmacológico , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/etiologia , Adulto , Feminino , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Prognóstico , Resultado do Tratamento
4.
Medicine (Baltimore) ; 99(16): e19875, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32312013

RESUMO

INTRODUCTION: Systemic lupus erythematosus (SLE) is a multisystem, chronic, autoimmune disease which can affect any organ system including the eye. About one-third of the patients can be diagnosed with SLE-related eye involvement which is usually indicative of disease activity. Retinopathy is one of the most vision-threatening complications that can be associated with the disease. PATIENT CONCERNS: An 11-year-old girl was hospitalized with complains of repeated swelling and pain in her extremities for 1 month, chest pain for 24 days, rash for 5 days and proteinuria for 1 day. On the morning of her fourth day in hospital, she suddenly complained of sudden, painless vision loss in the left eye. The ophthalmologist found that she had obstruction of central retinal vein and artery with diffuse retinal hemorrhages and macular edema. DIAGNOSIS: The patient was diagnosed with systemic lupus erythematosus, lupus nephritis, and lupus retinopathy through her clinical manifestations and laboratory tests. INTERVENTIONS: After diagnosis, she received steroid therapy, retinal laser photocoagulation, and intravitreal injection of dexamethasone (OZURDEX, Allergan Pharmaceuticals, Dublin, Ireland) early in her course. OUTCOMES: At the latest follow-up, her vision improved partially. However, she still has the possibility of subsequent neovascular glaucoma and bleeding in the future. CONCLUSIONS: An early diagnosis and the prompt therapeutic measures are necessary to prevent sight-threatening consequences, especially in pediatric patients with SLE.


Assuntos
Lúpus Eritematoso Sistêmico/complicações , Doenças Retinianas/etiologia , Doenças Retinianas/terapia , Transtornos da Visão/etiologia , Criança , Dexametasona/administração & dosagem , Dexametasona/uso terapêutico , Feminino , Glaucoma Neovascular/epidemiologia , Glaucoma Neovascular/etiologia , Glucocorticoides/administração & dosagem , Glucocorticoides/uso terapêutico , Hemorragia , Humanos , Injeções Intravítreas , Fotocoagulação a Laser/métodos , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/patologia , Nefrite Lúpica/complicações , Nefrite Lúpica/diagnóstico , Edema Macular , Oclusão da Artéria Retiniana/diagnóstico , Oclusão da Artéria Retiniana/etiologia , Doenças Retinianas/patologia , Oclusão da Veia Retiniana/diagnóstico , Oclusão da Veia Retiniana/etiologia , Resultado do Tratamento
5.
Ann Rheum Dis ; 79(6): 713-723, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32220834

RESUMO

OBJECTIVE: To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN). METHODS: Following the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force voted independently on their level of agreeement with the formed statements. RESULTS: The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNIs) and management of end-stage kidney disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7 g/24 hours with (near-)normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1 g/24 hours despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations. Treatment of LN in children follows the same principles as adult disease. CONCLUSIONS: We have updated the EULAR recommendations for the management of LN to facilitate homogenization of patient care.


Assuntos
Imunossupressores/uso terapêutico , Nefrite Lúpica/tratamento farmacológico , Sociedades Médicas , Antirreumáticos/uso terapêutico , Azatioprina/uso terapêutico , Inibidores de Calcineurina/uso terapêutico , Quimioterapia Combinada , Europa (Continente) , Taxa de Filtração Glomerular , Glucocorticoides/uso terapêutico , Humanos , Hidroxicloroquina/uso terapêutico , Falência Renal Crônica/etiologia , Falência Renal Crônica/terapia , Nefrite Lúpica/complicações , Nefrite Lúpica/patologia , Nefrite Lúpica/fisiopatologia , Ácido Micofenólico/uso terapêutico , Proteinúria/etiologia , Proteinúria/terapia
6.
Nat Rev Rheumatol ; 16(5): 255-267, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32203285

RESUMO

Lupus nephritis (LN) is a common manifestation of systemic lupus erythematosus that can lead to irreversible renal impairment. Although the prognosis of LN has improved substantially over the past 50 years, outcomes have plateaued in the USA in the past 20 years as immunosuppressive therapies have failed to reverse disease in more than half of treated patients. This failure might reflect disease complexity and heterogeneity, as well as social and economic barriers to health-care access that can delay intervention until after damage has already occurred. LN progression is still poorly understood and involves multiple cell types and both immune and non-immune mechanisms. Single-cell analysis of intrinsic renal cells and infiltrating cells from patients with LN is a new approach that will help to define the pathways of renal injury at a cellular level. Although many new immune-modulating therapies are being tested in the clinic, the development of therapies to improve regeneration of the injured kidney and to prevent fibrosis requires a better understanding of the mechanisms of LN progression. This mechanistic understanding, together with the development of clinical measures to evaluate risk and detect early disease and better access to expert health-care providers, should improve outcomes for patients with LN.


Assuntos
Rim/citologia , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Lúpus Eritematoso Sistêmico/patologia , Nefrite Lúpica/complicações , Biomarcadores/análise , Ensaios Clínicos como Assunto , Progressão da Doença , Diagnóstico Precoce , Fibrose/prevenção & controle , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Imunossupressores/uso terapêutico , Rim/lesões , Rim/metabolismo , Rim/patologia , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/prevenção & controle , Lúpus Eritematoso Sistêmico/epidemiologia , Nefrite Lúpica/genética , Nefrite Lúpica/imunologia , Prognóstico , Regeneração/efeitos dos fármacos , Regeneração/fisiologia , Fatores Socioeconômicos , Estados Unidos/epidemiologia
7.
Lupus ; 29(2): 213-215, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31924141

RESUMO

Systemic lupus erythematosus (SLE) is a hypercoagulable state due to a variety of mechanisms. Herein, we discuss the case of a 40-year-old gentleman who presented with cerebral venous sinus thrombosis (CVST) as the first manifestation of underlying SLE. On initial presentation, he did not endorse any other signs and symptoms to suggest the presence of an autoimmune condition. Work-up revealed an absence of antiphospholipid antibodies. Further evaluation uncovered the underlying etiology of the CVST as SLE-induced nephrotic syndrome. The existing literature on CVST suggests that there are only two other biopsy-proven cases of lupus nephritis leading to nephrotic range proteinuria as the etiology for CVST. Given the rarity of this presentation, there are no clearly delineated treatment strategies.


Assuntos
Rim/patologia , Nefrite Lúpica/complicações , Trombose dos Seios Intracranianos/diagnóstico por imagem , Adulto , Anticoagulantes/uso terapêutico , Humanos , Nefrite Lúpica/tratamento farmacológico , Nefrite Lúpica/patologia , Imagem por Ressonância Magnética , Masculino , Metilprednisolona/uso terapêutico , Microscopia Eletrônica , Trombose dos Seios Intracranianos/tratamento farmacológico
9.
Am J Perinatol ; 37(6): 570-576, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31910463

RESUMO

OBJECTIVE: Pregnancy on dialysis is rare and few studies in this population exist. Currently, pregnancy outcomes are thought to be related to dialysis intensity. We hypothesize women requiring dialysis due to diabetes or lupus will have worse pregnancy outcomes compared with other indications for dialysis. STUDY DESIGN: All women receiving dialysis during pregnancy from 2012 to 2016 in a single health system were identified. Differences in perinatal outcomes among those with renal failure caused by diabetes or lupus and with other causes were evaluated. RESULTS: Sixteen women were identified, seven with diabetes or lupus causing renal failure; the remaining nine women had hypertension, focal segmental glomerular sclerosis, polycystic kidney disease, congenital hypoplastic kidneys, or neurogenic bladder. The rates of composite maternal morbidity were similar among the two groups. Composite neonatal morbidity was higher in those with renal failure caused by diabetes or lupus compared with other causes (100% vs. 29%, p = 0.028). CONCLUSION: Despite similar dialysis intensity, the composite neonatal morbidity was higher in women with renal failure caused by diabetes or lupus compared with other etiologies. Our findings suggest that pregnancy outcome in women receiving dialysis is dependent on both the intensity of dialysis as well as the etiology of renal failure.


Assuntos
Nefropatias Diabéticas/complicações , Falência Renal Crônica/terapia , Lúpus Eritematoso Sistêmico/complicações , Nefrite Lúpica/complicações , Resultado da Gravidez , Gravidez em Diabéticas , Diálise Renal , Adulto , Feminino , Humanos , Falência Renal Crônica/etiologia , Gravidez , Complicações na Gravidez , Estudos Prospectivos , Estudos Retrospectivos , Adulto Jovem
10.
Mod Rheumatol ; 30(1): 125-131, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30557058

RESUMO

AbstractsBackground: Recent studies have identified the significance of proteinuria levels after initial induction therapies on the renal outcomes in patients with proliferative lupus nephritis, but the issue has not been evaluated in Japanese patients.Methods: Based on the ISN/RPS classification, only patients diagnosed with lupus nephritis class III or IV were included. The remission of proteinuria 12 months after diagnosis, as well as the clinicopathological features at diagnosis, on renal outcomes was examined retrospectively. Renal progression was defined as a 50% decrease in the estimated glomerular filtration rate or the development of end-stage renal disease.Results: This study included 82 Japanese patients with a median follow-up period of seven years. Although all patients received intensive induction therapy, 15 patients (18%) showed progression. Proteinuric remission 12 months after diagnosis predicted a good renal outcome by multivariate analysis. A receiver-operating characteristic analysis of 38 patients whose quantitative urinary protein excretion levels at 12 months were available for analysis showed that a cut-off value of 0.8 g/day predicted renal progression most effectively. Neither the renal function nor proteinuria level at diagnosis were associated with the renal outcomes.Conclusion: In Japanese patients with lupus nephritis class III or IV, proteinuria levels after 12 months under intensive therapy predicted renal outcomes more accurately than did factors identified at diagnosis.


Assuntos
Glucocorticoides/uso terapêutico , Imunossupressores/uso terapêutico , Rim/patologia , Nefrite Lúpica/terapia , Proteinúria/terapia , Indução de Remissão/métodos , Adolescente , Adulto , Idoso , Biópsia , Criança , Progressão da Doença , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Japão/epidemiologia , Rim/fisiopatologia , Nefrite Lúpica/complicações , Nefrite Lúpica/diagnóstico , Masculino , Pessoa de Meia-Idade , Proteinúria/epidemiologia , Proteinúria/etiologia , Curva ROC , Estudos Retrospectivos , Adulto Jovem
11.
Ren Fail ; 42(1): 19-29, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31858861

RESUMO

Renal microvascular lesions, common in lupus nephritis (LN), are associated with long-term poor outcomes. There are mainly five pathological types of renal microvascular lesions in LN: (1) vascular immune complex deposits (ICD), (2) arteriosclerosis (AS), (3) thrombotic microangiopathy (TMA), (4) non-inflammatory necrotizing vasculopathy (NNV), and (5) true renal vasculitis (TRV). The pathogenesis of renal microvascular lesions in LN remains to be elucidated. The activation and dysfunction of endothelial cells, in addition to the contribution of immune system dysfunction, especially the immune complex-induced vascular inflammation and antiphospholipid antibody-associated thrombotic events, are key mechanisms in the development of vascular lesions in LN that need to be further investigated. Alteration of the microvascular environment produces an acute immunological response that recruits immune cells, such as T cells, monocytes, and macrophages, which induces platelet aggregation with microthrombus formation. There is also increased cytotoxicity caused by cytokines produced by immune cells in the kidney. Identifying the mechanism underlying the pathogenesis of renal microvascular lesions in LN might provide potential targets for the development of novel therapies.


Assuntos
Rim/irrigação sanguínea , Nefrite Lúpica/complicações , Doenças Vasculares/imunologia , Células Endoteliais/imunologia , Células Endoteliais/patologia , Endotélio Vascular/citologia , Endotélio Vascular/imunologia , Endotélio Vascular/patologia , Humanos , Rim/imunologia , Nefrite Lúpica/imunologia , Microvasos/imunologia , Microvasos/patologia , Literatura de Revisão como Assunto , Doenças Vasculares/patologia
12.
Lupus ; 29(1): 83-91, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31801041

RESUMO

OBJECTIVE: We analyzed baseline and follow-up characteristics related to poorer renal outcomes in a Brazilian cohort of admixture race patients with lupus nephritis. METHODS: Overall, 280 outpatients with a diagnosis of systemic lupus erythematosus and previous kidney biopsy of lupus nephritis were recruited from August 2015 to December 2018 and had baseline laboratory and histologic data retrospectively analyzed; patients were then followed-up and data were recorded. The main outcome measure was the estimated glomerular filtration rate at last follow-up. Secondary analyses assessed the impact of initial kidney histology and treatment in long-term kidney survival. RESULTS: Median duration of lupus nephritis was 60 months (interquartile range: 27-120); 40 (14.3%) patients presented progressive chronic kidney disease (estimated glomerular filtration rate <30 and ≥10 ml/min/1.73 m2) or end-stage kidney disease at last visit. Adjusted logistic regression analysis showed that class IV lupus nephritis (odds ratio 14.91; 95% confidence interval 1.77-125.99; p = 0.01) and interstitial fibrosis ≥25% at initial biopsy (odds ratio 5.87; 95% confidence interval 1.32-26.16; p = 0.02), lack of complete or partial response at 12 months (odds ratio 16.3; 95% confidence interval 3.74-71.43; p < 0.001), and a second renal flare (odds ratio 4.49; 95% confidence interval 1.10-18.44; p = 0.04) were predictors of progressive chronic kidney disease. In a Kaplan-Meier survival curve we found that class IV lupus nephritis and interstitial fibrosis ≥25% were significantly associated with end-stage kidney disease throughout follow-up (hazard ratio 2.96; 95% confidence interval 1.3-7.0; p = 0.036 and hazard ratio 4.96; 95% confidence interval 1.9-12.9; p < 0.0001, respectively). CONCLUSION: In this large cohort of admixture race patients, class IV lupus nephritis and chronic interstitial damage at initial renal biopsy together with non-response after 1 year of therapy and relapse were associated with worse long-term renal outcomes.


Assuntos
Progressão da Doença , Falência Renal Crônica/etiologia , Nefrite Lúpica/fisiopatologia , Adulto , Brasil , Estudos de Coortes , Feminino , Taxa de Filtração Glomerular , Humanos , Nefrite Lúpica/classificação , Nefrite Lúpica/complicações , Masculino , Pessoa de Meia-Idade
13.
Matronas prof ; 20/21(4/1): e10-e15, 2019-2020.
Artigo em Espanhol | IBECS | ID: ibc-192427

RESUMO

OBJETIVO: El objetivo de esta revisión es conocer los aspectos más relevantes para una adecuada planificación pregestacional, el seguimiento del embarazo y el posparto en las mujeres con lupus eritematoso sistémico. METODOLOGÍA: Se realizó una búsqueda bibliográfica de los artículos publicados en las siguientes bases de datos: PubMed, Cochrane Plus, Biblioteca de Salud Reproductiva de la Organización Mundial de la Salud, Uptodate y Cuiden. También fueron consultadas las guías de práctica clínica del Sistema Nacional de Salud, así como la página de la Federación Española de Lupus. RESULTADOS: En el pasado, no se recomendaba a las mujeres con LES quedarse embarazadas por temor a las complicaciones. Actualmente, se ha logrado mejorar la frecuencia de embarazos exitosos, aun así la actividad del LES durante el embarazo es un tema controvertido. Entre las principales complicaciones encontramos: preeclampsia, nefritis lúpica, síndrome antifosfolípidos y lupus neonatal entre otras. CONCLUSIONES: La planificación, consulta preconcepcional y seguimiento multidisciplinar adquieren gran relevancia ya que determinan el curso y pronóstico del embarazo. Así, la complicación más frecuente es la preeclampsia y la que conlleva mayores tasas de complicaciones maternofetales es la nefritis lúpica, llegando a ser la diferenciación entre ambas un gran desafío


OBJECTIVE: The aim of this review is to know the most relevant aspects of adequating pregestational planning, pregnancy and postpartum follow-up in women with systemic lupus erythematosus.METHODOLOGY: A literature search was undertaken in the following databases: PubMed, Cochrane Plus, WHO Reproductive Health Library, Uptodate and Cuiden. Besides, the clinical practice guidelines of the National Health System were reviewed as well as the Spanish Lupus Federation website. RESULTS: In the past, women with SLE were not advised to become pregnant for fear of complications. Currently, it has been possible to improve the frequency of successful pregnancies, even though the activity of SLE during pregnancy is a controversial issue. Among the main com-plications are: preeclampsia, lupus nephritis, antiphospholipid syndrome and neonatal lupus among others. CONCLUSIONS: The planning, preconception consultation and multidisciplinary follow-up acquires great relevance since it determines the course and prognosis of pregnancy. Thus, the most frequent complication is preeclampsia and the one with the highest rates of maternal-fetal complications is lupus neph


Assuntos
Humanos , Feminino , Gravidez , Complicações na Gravidez/epidemiologia , Lúpus Eritematoso Sistêmico/complicações , Pré-Eclâmpsia , Nefrite Lúpica/complicações , Síndrome Antifosfolipídica , Período Pós-Parto , Trabalho de Parto
14.
Pol Arch Intern Med ; 129(12): 874-882, 2019 12 23.
Artigo em Inglês | MEDLINE | ID: mdl-31808753

RESUMO

INTRODUCTION: Long­term glucocorticoid (GC) therapy is the most common cause of secondary adrenal insufficiency (AI), which undiagnosed may lead to life­threatening adrenal crisis. OBJECTIVES: The aim of the study was to evaluate AI in patients treated long­term with GCs, receiving a low maintenance dose (≤5 mg of prednisone or equivalent), namely, its prevalence and persistence, risk factors, and diagnostic accuracy of morning cortisol and dehydroepiandrosterone sulfate (DHEA­S) levels. PATIENTS AND METHODS: Adrenal function was evaluated in 40 patients before and after GC withdrawal and at least 1 year later. Based on morning cortisol levels and short Synacthen test, patients were divided into 3 groups: AI, intermediate (partial AI), and AS (adrenal sufficiency). Receiver operator characteristic curves were calculated to assess the diagnostic value of morning cortisol and DHEA­S levels before GC withdrawal. RESULTS: Before GC withdrawal, 42.5% of patients had AI or partial AI, which together persisted in 64.3% of those patients after withdrawal. After more than a year, the adrenal function returned to normal only in 14% of patients. Cushingoid feature occurred more often in the AI group compared with the AS group (60% vs 13%; P = 0.03). Morning cortisol levels of 14.91 µg/dl or higher (411 nmol/l) gave 100% negative predictive value to rule out AI. Morning cortisol of 6.51 µg/dl or less (179.6 nmol/l) gave 100% positive predictive value to rule in AI. DHEA­S proved to be a worse parameter for AI diagnosis. CONCLUSIONS: AI is common in patients treated with GCs and may persist for years after GC withdrawal. Cushingoid features are associated with a higher risk of AI. Morning cortisol levels may facilitate AI diagnosis.


Assuntos
Insuficiência Adrenal/induzido quimicamente , Insuficiência Adrenal/diagnóstico , Glomerulonefrite por IGA/tratamento farmacológico , Glucocorticoides/efeitos adversos , Glucocorticoides/uso terapêutico , Nefrite Lúpica/tratamento farmacológico , Suspensão de Tratamento/estatística & dados numéricos , Insuficiência Adrenal/epidemiologia , Adulto , Idoso , Feminino , Glomerulonefrite por IGA/complicações , Humanos , Nefrite Lúpica/complicações , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Transplantados , Adulto Jovem
15.
Perit Dial Int ; 39(6): 570-573, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31690702

RESUMO

The long-term clinical outcomes of peritoneal dialysis (PD) for patients with lupus nephritis (LN) have not been well researched. In the present study, we investigated the long-term prognosis of a Chinese PD cohort. This was a retrospective case-control study that included LN patients receiving PD treatment for more than 90 days from January 2006 to December 2012. Non-diabetic control patients were selected using a ratio of 1:2 for age- and gender-matching. The primary outcome was all-cause mortality. Secondary outcomes included technique failure and hospitalization rate. All patients were followed up to 31 December 2017. A total of 28 LN patients on PD (89.3% female, mean age 42.2±15.8 years) and 56 controls were included. After a median follow-up period of 53.1 months, 11 LN patients died. The cumulative 1-, 3-, and 5-year patient survival rates were 92.4%, 84.7%, and 67.6% in LN patients, and 100%, 93.5%, and 82.9% in the control group, respectively (p = 0.035). After adjusting for confounders, LN was not significantly associated with mortality (hazard ratio [HR]: 1.39, 95% confidence interval [CI]: 0.45 - 4.26); However, LN was still an independent risk factor of technique failure (HR: 2.87, 95% CI: 1.08 - 7.66). Meanwhile, the LN group had significantly higher hospitalization and infection rates. In conclusion, LN patients undergoing PD had poor patient survival and technique survival, and higher hospitalization and infection rates.


Assuntos
Falência Renal Crônica/terapia , Nefrite Lúpica/complicações , Diálise Peritoneal/métodos , Adulto , Estudos de Casos e Controles , China/epidemiologia , Feminino , Seguimentos , Humanos , Falência Renal Crônica/etiologia , Nefrite Lúpica/mortalidade , Nefrite Lúpica/terapia , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo
16.
BMC Nephrol ; 20(1): 425, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752733

RESUMO

BACKGROUND: Pregnancy is rare in women on hemodialysis. Recommendations for the treatment of secondary hyperparathyroidism (sHPT) and preservation of bone health in pregnant dialysis patients are lacking. CASE PRESENTATION: We present the case of a young woman with end-stage kidney disease (ESKD) due to lupus nephritis, who developed multiple brown tumors while on hemodialysis during her second pregnancy. During her first pregnancy sHPT was well controlled and no skeletal complications occurred. Before the second pregnancy she developed severe sHPT. During pregnancy, dialysis time was increased to 24 h per week, the patient was given oral calcitriol, and the dialysate calcium concentration was set at 1.5 mmol/l. In week 20 the patient complained about bone pain in her left hip. Magnetic resonance imaging revealed a cystic lesion compatible with a brown tumor. The baby was delivered in the 36th week by cesarean section. Further assessment identified multiple brown tumors of her skeleton, including the acetabulum, tibia, ribs, skull, thoracic spine and thumb. She required multiple orthopedic surgeries. Three months after pregnancy, etelcalcetide was started, which brought about a gradual improvement in her sHPT. CONCLUSIONS: This case demonstrates that the combination of pregnancy and severe sHPT in dialysis patients can have deleterious consequences for bone health.


Assuntos
Hiperparatireoidismo Secundário/complicações , Falência Renal Crônica/terapia , Nefrite Lúpica/complicações , Osteíte Fibrosa Cística/etiologia , Complicações na Gravidez , Diálise Renal/efeitos adversos , Adulto , Cálcio/sangue , Feminino , Humanos , Hiperparatireoidismo Secundário/sangue , Hiperparatireoidismo Secundário/tratamento farmacológico , Falência Renal Crônica/sangue , Falência Renal Crônica/etiologia , Osteíte Fibrosa Cística/diagnóstico por imagem , Osteíte Fibrosa Cística/cirurgia , Hormônio Paratireóideo/sangue , Peptídeos/uso terapêutico , Gravidez , Complicações na Gravidez/sangue , Complicações na Gravidez/terapia
17.
Lupus ; 28(14): 1727-1734, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31635558

RESUMO

INTRODUCTION: Treatment of lupus nephritis class III, IV and V with immunosuppressive therapy increases patient survival but poses a risk of infection-related mortality. This study was conducted to evaluate risk factors for fatal infection in children with lupus nephritis in under-resourced areas. METHODS: Medical records of patients, who were admitted to a tertiary-care university-based hospital from January 2002 to July 2018 with the diagnosis of systemic lupus erythematosus, were reviewed. Only patients aged less than 18 years with lupus nephritis and documented infection were included in the study. The primary outcome was infection-associated mortality. The logistic regression model was used to identify independent variables associated with fatal infection. Predicted probabilities of infection-related mortality adjusted for factors significant in multivariate analysis were calculated using marginal effects at representative values. RESULTS: Infection-related deaths occurred in 27 of 179 patients (15.1%). Hospital-acquired infections occurred in 72 of 375 episodes of hospital admissions (19.2%) and 13 hospital-acquired infections (18.1%) resulted in fatal infection. Invasive fungal infections were the leading cause of death (44.4%) and pulmonary infections were the predominant site (55.5%). Haemoglobin levels and glomerular filtration rates were significantly lower in deceased versus surviving patients. Percentages of patients with hospital-acquired infections, invasive fungal infections and pulmonary infections were significantly higher in deceased than surviving patients. Urine protein, the neutrophil-to-lymphocyte ratio, cumulative methylprednisolone dose and daily prednisolone dose were significantly higher in deceased than surviving patients. In multivariate analysis, a neutrophil-to-lymphocyte ratio more than 20, invasive fungal infections and high daily prednisolone dose were independently predictive of fatal infection with adjusted odds ratio of 3.02 (95% confidence interval 1.02-8.97, p = 0.04), 15.08 (95% confidence interval 4.72-48.24, p < 0.001) and 1.03 (95% confidence interval 1.01-1.06, p = 0.04), respectively. A high daily prednisolone dose intensified the impact of invasive fungal infections and high neutrophil-to-lymphocyte ratio on predicted probability of infection-associated mortality. CONCLUSIONS: Prevention of invasive fungal infections and minimization of daily prednisolone should be emphasized in routine clinical practice of children with lupus nephritis in under-resourced areas to achieve better survival. Children with lupus nephritis and a high neutrophil-to-lymphocyte ratio should be under cautious surveillance for infection.


Assuntos
Infecção Hospitalar/mortalidade , Nefrite Lúpica/complicações , Nefrite Lúpica/tratamento farmacológico , Micoses/mortalidade , Adolescente , Criança , Infecção Hospitalar/etiologia , Ciclofosfamida/uso terapêutico , Feminino , Glucocorticoides/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Modelos Logísticos , Nefrite Lúpica/mortalidade , Masculino , Metilprednisolona/uso terapêutico , Análise Multivariada , Micoses/etiologia , Prednisolona/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Tailândia/epidemiologia
18.
Horm Mol Biol Clin Investig ; 40(3)2019 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-31553696

RESUMO

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE. Materials and methods We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed. Results The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006). Conclusions Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.


Assuntos
Lúpus Eritematoso Sistêmico/complicações , Complicações na Gravidez/diagnóstico , Adulto , Feminino , Humanos , Recém-Nascido , Nefrite Lúpica/complicações , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/etiologia , Gravidez , Complicações na Gravidez/etiologia , Resultado da Gravidez , Estudos Retrospectivos
20.
Lupus ; 28(11): 1312-1319, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31495267

RESUMO

OBJECTIVES: To investigate the fetal adverse pregnancy outcomes (APOs) and the predictive value of umbilical arterial Doppler ultrasonography in the third trimester in pregnant women with lupus nephritis (LN). METHODS: A retrospective cohort study enrolling 203 LN patients from 2007 to 2017 was performed. Ultrasonic parameters were recorded. RESULTS: Fetal APOs occurred in 103 patients (103/203, 50.7%). Sixty-six pregnancies (66/203, 32.5%) ended with preterm births. The incidence rate of intrauterine growth restriction (IUGR) was 18.2% (37/203). Fetal distress was noted in 23 pregnancies (23/203, 11.3%). All the Doppler parameters elevated in patients with IUGR, fetal distress, and composite conditions. Resistance index (RI) indicated the highest risk of IUGR and composite APOs. The cutoff values were 0.66 and 0.67, respectively. Sensitivities were 51.4% and 33.7%, and specificities were 87.4% and 92.1%. Peak velocity of the umbilical arteries at end-systole (Vmax, abbreviated as S) to that at end-diastole (Vmin, abbreviated as D) (S/D) ratio was also a best predictor for IUGR, with the optimal cutoff value of 2.88. Sensitivity and specificity were comparable with RI. Pulsatility index (PI) over 0.84 was an ideal indicator for fetal distress with an optimal combination of sensitivity (89.5%) and specificity (51.6%). CONCLUSIONS: Fetal complications were frequent in patients with LN. Umbilical arterial Doppler ultrasonography was a useful measure to predict late IUGR, fetal distress, and the composite APOs.


Assuntos
Nefrite Lúpica/complicações , Complicações na Gravidez/fisiopatologia , Ultrassonografia Doppler/métodos , Ultrassonografia Pré-Natal/métodos , Adolescente , Adulto , China , Estudos de Coortes , Feminino , Retardo do Crescimento Fetal/epidemiologia , Humanos , Recém-Nascido , Valor Preditivo dos Testes , Gravidez , Resultado da Gravidez , Terceiro Trimestre da Gravidez , Estudos Retrospectivos , Sensibilidade e Especificidade , Artérias Umbilicais/diagnóstico por imagem , Adulto Jovem
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