University of Edinburgh
Lupus-like nephritis with associated seronegative antiphospholipid syndrome Diagnostic DilemmaThe American Journal of MedicineRuaraidh F Stewart? MB BChirChristopher O C Bellamy? MDPhD, FRCPathDavid C Kluth? MDPhDNeeraj Dhaun MDPhDBHF Centre of Research Excellence, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh. EH16 4TJ?Department of Renal Medicine, Royal Infirmary of Edinburgh?Department of Pathology, Royal Infirmary of Edinburgh, UKCorrespondence to: Dr Neeraj DhaunThe Queen’s Medical Research Institute47 Little France CrescentEdinburgh. EH16 4TJTelephone: (+44)-131-242-9215E-mail: bean.dhaun@ed.ac.ukNo of words: 1,500Tables:1Figures: 1Pages: 10ND is supported by a British Heart Foundation Intermediate Clinical Research Fellowship (FS/13/30/29994).All authors contributed to the writing and critical appraisal of the manuscript.None of the authors have any conflicts of interest.Key words: SLE; antiphospholipid syndromeRunning title: Seronegative lupus nephritis & antiphospholipid syndromePresentationSystemic lupus erythematosus and antiphospholipid syndrome are autoimmune disorders with diagnostic criteria, including the identification of characteristic autoantibodies. For those without a diagnosis of systemic lupus erythematosus but with characteristic histological findings on kidney biopsy, a diagnosis of lupus-like glomerulonephritis has been suggested. The management of such patients, as well as those with a clinical syndrome of antiphospholipid syndrome without supporting serology, is controversial. A 56 year-old woman presented with nephrotic syndrome describing lethargy and a rash. Recently diagnosed with bilateral pulmonary emboli following a long-haul flight, she was taking warfarin. There was no other history of thrombosis or miscarriages. Assessment & managementSerum creatinine had risen from 0.79 to 1.41mg/dL within 6 weeks and urinalysis showed hematuria +++ and proteinuria +++. Examination revealed vitiligo, a butterfly rash and mild pedal edema. Blood pressure (BP) was 132/92mmHg. Initial investigations are shown in Table 1. A computerised tomography (CT) scan revealed widespread lymphadenopathy and a lymph node biopsy showed non-specific reactive lymphoid hyperplasia. A renal biopsy was organised with warfarin stopped 3 days prior to this and re-started after 24 hours. There was no bridging anticoagulation.Renal biopsy (Figure, panels A & B)Of the 11 glomeruli on light microscopy 2 were globally sclerosed, 2 displayed segmental sclerosing and necrotizing lesions with tuft-capsule adhesion. All glomeruli showed mild mesangial proliferation. There was diffuse moderate interstitial fibrosis and tubular atrophy. A portion of an interlobular artery showed minimal intimal fibrosis. Immunofluorescence revealed glomerular, mesangial and membranous deposits for pan-IgG, C3, C1q with weak staining for IgG4. Electron microscopy showed scattered sub-epithelial electron dense deposits with tubuloreticular bodies evident within the endothelium. These findings were in keeping with an active chronic class III A/C and class V membranous lupus-type glomerulonephritis. At clinic review 1 week later the diagnosis of lupus-like nephropathy was explained. BP was 132/74mmHg and serum creatinine 1.36mg/dL. The patient was started on prednisone 60mg once daily and mycofenolate mofetil 500mg twice daily.Six weeks later the patient was symptomatically improved. However, BP was now 175/113mmHg and the peripheral edema had increased. Serum creatinine had risen to 4.85mg/dL. Imaging excluded renal vein thromboses. A repeat kidney biopsy was arranged following reversal of warfarin and with bridging anticoagulation using intravenous heparin.Second renal biopsy (Figure, panels C-E)In addition to the glomerular changes seen in the first biopsy an interlobular artery showed pronounced intimal edema with myointimal proliferation, medial dilation and thinning, but no fresh fibrin thrombus or arteritis. The findings confirmed the presence of a sub-acute malignant vascular injury. Given its absence on the previous biopsy consideration was given to a concurrent sub-acute antiphospholipid-related thrombotic microangiopathy. Taken together these changes raised the possibility of both a glomerulonephritis and an extra-glomerular vasculopathy causing ongoing progressive kidney damage. Apart from a 6-hour period around the time of the second biopsy the patient was fully anticoagulated. 7 days following the biopsy the patient developed a large left retroperitoneal hematoma on the same side as the kidney biopsy. Alongside reversal of anticoagulation this required radiological embolization. The mycofenolate mofetil was withdrawn due to pancytopenia.After one month the patient was discharged home. She had a serum creatinine of 3.19mg/dL, remained nephrotic and was not anticoagulated. At clinic review 2 weeks later she described left pleuritic chest discomfort. A CT pulmonary angiogram showed new bilateral pulmonary emboli. The patient was re-commenced on warfarin on which she remains life-long for a diagnosis of seronegative antiphospholipid syndrome secondary to a lupus-like illness. She was also treated with rituximab and the prednisone gradually withdrawn. She remains well with a serum creatinine of 1.42mg/dL.DiagnosisI. Seronegative systemic lupus erythematosus with renal involvementII. Secondary seronegative antiphospholipid syndrome.We present a complex patient presenting with nephrotic syndrome. We believe this was a manifestation of lupus-like nephritis in the setting of seronegative systemic lupus erythematosus. The decline in renal function following biopsy was likely due to active antiphospholipid syndrome attributable to a period of inadequate anticoagulation around the time of the kidney biopsy and manifesting as a thrombotic microangiopathy. This case also highlights the risks of kidney biopsy in those with a bleeding and thrombotic tendency. Systemic lupus erythematosus is usually diagnosed following identification of circulating autoantibodies commonly including anti-nuclear (ANA), double-stranded DNA and anti-Smith antibodies. This patient had an ANA titre of 1/160 (common in the general population) and was negative for these other antibodies. The kidney is commonly involved. ADDIN EN.CITE <EndNote><Cite><Author>Cameron</Author><Year>1999</Year><RecNum>1940</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>1940</rec-number><foreign-keys><key app="EN" db-id="wft50wp9xr92tke5tz8pssfv0tw5xwxdwaxv" timestamp="1344251907">1940</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cameron, J. S.</author></authors></contributors><auth-address>Renal Unit, Guy's Hospital, King's College, London, United Kingdom. jstewart_cameron@email.</auth-address><titles><title>Lupus nephritis</title><secondary-title>J Am Soc Nephrol</secondary-title><alt-title>Journal of the American Society of Nephrology : JASN</alt-title></titles><periodical><full-title>J Am Soc Nephrol</full-title><abbr-1>Journal of the American Society of Nephrology : JASN</abbr-1></periodical><alt-periodical><full-title>J Am Soc Nephrol</full-title><abbr-1>Journal of the American Society of Nephrology : JASN</abbr-1></alt-periodical><pages>413-24</pages><volume>10</volume><number>2</number><edition>1999/04/24</edition><keywords><keyword>Autoimmunity/physiology</keyword><keyword>Humans</keyword><keyword>Kidney/pathology/physiopathology</keyword><keyword>Lupus Nephritis/diagnosis/immunology/pathology/*physiopathology/*therapy</keyword><keyword>Mortality</keyword><keyword>Prognosis</keyword></keywords><dates><year>1999</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1046-6673 (Print)
1046-6673 (Linking)</isbn><accession-num>10215343</accession-num><work-type>Review</work-type><urls><related-urls><url> Histologic findings in lupus nephritis typically include (1) deposition of IgG, IgA, IgM, C3 and C1q (often referred to as ‘full-house’ staining), (2) extra-glomerular immune deposits within the tubular basement membrane, (3) immune deposits within all glomerular compartments, and (4) tubuloreticular inclusions seen on electron microscopy. Our patient had histology consistent with lupus nephritis but insufficient clinical and serological evidence of systemic lupus erythematosus and so was given a diagnosis of ‘lupus-like nephritis’. Previous reports of thisPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdWVydGE8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdWVydGE8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS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ADDIN EN.CITE.DATA 2 suggest renal outcomes are poor. Furthermore, the paucity of data makes management difficult. Antiphospholipid syndrome is a unique form of autoantibody-induced thrombophilia, characterised by recurrent (arterial and/or venous) thrombosis and pregnancy complications. From a renal perspective, patients are at risk of vascular lesions, including renal artery stenosis, renal vein thrombosis,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5VdGhtYW48L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxS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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5VdGhtYW48L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxS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ADDIN EN.CITE.DATA 3 and antiphospholipid syndrome nephropathy – a variety of acute (thrombotic microangiopathy) or chronic (fibrous intimal hyperplasia, focal cortical atrophy) vascular changes.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ob2NoeTwvQXV0aG9yPjxZZWFyPjE5OTk8L1llYXI+PFJl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 EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ob2NoeTwvQXV0aG9yPjxZZWFyPjE5OTk8L1llYXI+PFJl
Y051bT4yMzMwPC9SZWNOdW0+PERpc3BsYXlUZXh0PjxzdHlsZSBmYWNlPSJzdXBlcnNjcmlwdCI+
NDwvc3R5bGU+PC9EaXNwbGF5VGV4dD48cmVjb3JkPjxyZWMtbnVtYmVyPjIzMzA8L3JlYy1udW1i
ZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ3ZnQ1MHdwOXhyOTJ0a2U1dHo4
cHNzZnYwdHc1eHd4ZHdheHYiIHRpbWVzdGFtcD0iMTM4MjM2NjIyMCI+MjMzMDwva2V5PjwvZm9y
ZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48
Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Tm9jaHksIEQuPC9hdXRob3I+PGF1dGhvcj5E
YXVnYXMsIEUuPC9hdXRob3I+PGF1dGhvcj5Ecm96LCBELjwvYXV0aG9yPjxhdXRob3I+QmVhdWZp
bHMsIEguPC9hdXRob3I+PGF1dGhvcj5HcnVuZmVsZCwgSi4gUC48L2F1dGhvcj48YXV0aG9yPlBp
ZXR0ZSwgSi4gQy48L2F1dGhvcj48YXV0aG9yPkJhcmlldHksIEouPC9hdXRob3I+PGF1dGhvcj5I
aWxsLCBHLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPlNl
cnZpY2UgZCZhcG9zO0FuYXRvbWllIFBhdGhvbG9naXF1ZSwgSW5zdGl0dXQgTmF0aW9uYWwgZGUg
bGEgU2FudGUgZXQgZGUgbGEgUmVjaGVyY2hlIE1lZGljYWxlLCBVNDMwLCBIb3BpdGFsIEJyb3Vz
c2FpcywgUGFyaXMsIEZyYW5jZS48L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5UaGUgaW50
cmFyZW5hbCB2YXNjdWxhciBsZXNpb25zIGFzc29jaWF0ZWQgd2l0aCBwcmltYXJ5IGFudGlwaG9z
cGhvbGlwaWQgc3luZHJvbWU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+SiBBbSBTb2MgTmVwaHJv
bDwvc2Vjb25kYXJ5LXRpdGxlPjxhbHQtdGl0bGU+Sm91cm5hbCBvZiB0aGUgQW1lcmljYW4gU29j
aWV0eSBvZiBOZXBocm9sb2d5IDogSkFTTjwvYWx0LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2Fs
PjxmdWxsLXRpdGxlPkogQW0gU29jIE5lcGhyb2w8L2Z1bGwtdGl0bGU+PGFiYnItMT5Kb3VybmFs
IG9mIHRoZSBBbWVyaWNhbiBTb2NpZXR5IG9mIE5lcGhyb2xvZ3kgOiBKQVNOPC9hYmJyLTE+PC9w
ZXJpb2RpY2FsPjxhbHQtcGVyaW9kaWNhbD48ZnVsbC10aXRsZT5KIEFtIFNvYyBOZXBocm9sPC9m
dWxsLXRpdGxlPjxhYmJyLTE+Sm91cm5hbCBvZiB0aGUgQW1lcmljYW4gU29jaWV0eSBvZiBOZXBo
cm9sb2d5IDogSkFTTjwvYWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2VzPjUwNy0xODwvcGFn
ZXM+PHZvbHVtZT4xMDwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxlZGl0aW9uPjE5OTkvMDMv
MTI8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkdWx0PC9rZXl3b3JkPjxrZXl3b3JkPkFu
dGlib2RpZXMsIEFudGlwaG9zcGhvbGlwaWQvKmFuYWx5c2lzPC9rZXl3b3JkPjxrZXl3b3JkPkFu
dGlwaG9zcGhvbGlwaWQgU3luZHJvbWUvY29tcGxpY2F0aW9ucy8qcGF0aG9sb2d5PC9rZXl3b3Jk
PjxrZXl3b3JkPkJpb3BzeSwgTmVlZGxlPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29y
ZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtleXdvcmQ+S2lkbmV5L2Jsb29kIHN1cHBseS9w
YXRob2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+S2lkbmV5IERpc2Vhc2VzL2V0aW9sb2d5L2ltbXVu
b2xvZ3kvKnBhdGhvbG9neTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3Jk
Pk1pZGRsZSBBZ2VkPC9rZXl3b3JkPjxrZXl3b3JkPlByb2dub3Npczwva2V5d29yZD48a2V5d29y
ZD5SZW5hbCBBcnRlcnkgT2JzdHJ1Y3Rpb24vZXRpb2xvZ3kvKnBhdGhvbG9neTwva2V5d29yZD48
a2V5d29yZD5SZXRyb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+U2V2ZXJpdHkg
b2YgSWxsbmVzcyBJbmRleDwva2V5d29yZD48a2V5d29yZD5UaHJvbWJvcGhsZWJpdGlzL2V0aW9s
b2d5L3BhdGhvbG9neTwva2V5d29yZD48a2V5d29yZD5UaHJvbWJvc2lzL2V0aW9sb2d5LypwYXRo
b2xvZ3k8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MTk5OTwveWVhcj48cHViLWRh
dGVzPjxkYXRlPk1hcjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwNDYtNjY3MyAo
UHJpbnQpJiN4RDsxMDQ2LTY2NzMgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjEwMDcz
NjAxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5j
YmkubmxtLm5paC5nb3YvcHVibWVkLzEwMDczNjAxPC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxz
PjxsYW5ndWFnZT5lbmc8L2xhbmd1YWdlPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+
ADDIN EN.CITE.DATA 4 Diagnosing antiphospholipid syndrome relies on a clinical manifestation alongside laboratory evidence of a persisting circulating antiphospholipid antibody.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaXlha2lzPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaXlha2lzPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48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ADDIN EN.CITE.DATA 5 This patient did not have antiphospholipid antibodies but did have recurrent thromboses alongside evidence of acute antiphospholipid syndrome-like nephropathy. Furthermore, this developed upon withdrawal of standard treatment for antiphospholipid syndrome (warfarin). Thus, we diagnosed ‘seronegative antiphospholipid syndrome’.~40% of patients with systemic lupus erythematosus have antiphospholipid antibodies but <40% of these will develop thrombosis. Although thrombotic antiphospholipid syndrome is a poor prognostic factor in systemic lupus erythematosus it is uncommon in the absence of antiphospholipid antibodies.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZWt0b25pZG91PC9BdXRob3I+PFllYXI+MjAwNDwvWWVh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 EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZWt0b25pZG91PC9BdXRob3I+PFllYXI+MjAwNDwvWWVh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 EN.CITE.DATA 6 Although this patient’s first episode of pulmonary embolism followed a long-haul flight this is not a significant risk factor for pulmonary embolism with an incidence of 1/1,000,000 – 1/5,000,000.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZXJlei1Sb2RyaWd1ZXo8L0F1dGhvcj48WWVhcj4yMDAz
PC9ZZWFyPjxSZWNOdW0+MjMzMTwvUmVjTnVtPjxEaXNwbGF5VGV4dD48c3R5bGUgZmFjZT0ic3Vw
ZXJzY3JpcHQiPjc8L3N0eWxlPjwvRGlzcGxheVRleHQ+PHJlY29yZD48cmVjLW51bWJlcj4yMzMx
PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0id2Z0NTB3cDl4
cjkydGtlNXR6OHBzc2Z2MHR3NXh3eGR3YXh2IiB0aW1lc3RhbXA9IjEzODIzNjcxMTciPjIzMzE8
L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv
cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlBlcmV6LVJvZHJpZ3Vleiwg
RS48L2F1dGhvcj48YXV0aG9yPkppbWVuZXosIEQuPC9hdXRob3I+PGF1dGhvcj5EaWF6LCBHLjwv
YXV0aG9yPjxhdXRob3I+UGVyZXotV2FsdG9uLCBJLjwvYXV0aG9yPjxhdXRob3I+THVxdWUsIE0u
PC9hdXRob3I+PGF1dGhvcj5HdWlsbGVuLCBDLjwvYXV0aG9yPjxhdXRob3I+TWFuYXMsIEUuPC9h
dXRob3I+PGF1dGhvcj5ZdXNlbiwgUi4gRC48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRv
cnM+PGF1dGgtYWRkcmVzcz5QbmV1bW9sb2d5IERlcGFydG1lbnQsIFJhbW9uIHkgQ2FqYWwgSG9z
cGl0YWwsIE1hZHJpZCwgU3BhaW4uPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+SW5jaWRl
bmNlIG9mIGFpciB0cmF2ZWwtcmVsYXRlZCBwdWxtb25hcnkgZW1ib2xpc20gYXQgdGhlIE1hZHJp
ZC1CYXJhamFzIGFpcnBvcnQ8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJjaCBJbnRlcm4gTWVk
PC9zZWNvbmRhcnktdGl0bGU+PGFsdC10aXRsZT5BcmNoaXZlcyBvZiBpbnRlcm5hbCBtZWRpY2lu
ZTwvYWx0LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFyY2ggSW50ZXJu
IE1lZDwvZnVsbC10aXRsZT48YWJici0xPkFyY2hpdmVzIG9mIGludGVybmFsIG1lZGljaW5lPC9h
YmJyLTE+PC9wZXJpb2RpY2FsPjxhbHQtcGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BcmNoIEludGVy
biBNZWQ8L2Z1bGwtdGl0bGU+PGFiYnItMT5BcmNoaXZlcyBvZiBpbnRlcm5hbCBtZWRpY2luZTwv
YWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2VzPjI3NjYtNzA8L3BhZ2VzPjx2b2x1bWU+MTYz
PC92b2x1bWU+PG51bWJlcj4yMjwvbnVtYmVyPjxlZGl0aW9uPjIwMDMvMTIvMTA8L2VkaXRpb24+
PGtleXdvcmRzPjxrZXl3b3JkPkFnZWQ8L2tleXdvcmQ+PGtleXdvcmQ+KkFpcmNyYWZ0PC9rZXl3
b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtl
eXdvcmQ+SW5jaWRlbmNlPC9rZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+
UHVsbW9uYXJ5IEVtYm9saXNtLyplcGlkZW1pb2xvZ3kvZXRpb2xvZ3kvcHJldmVudGlvbiAmYW1w
OyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPlJldHJvc3BlY3RpdmUgU3R1ZGllczwva2V5d29y
ZD48a2V5d29yZD5SaXNrIEZhY3RvcnM8L2tleXdvcmQ+PGtleXdvcmQ+U3luZHJvbWU8L2tleXdv
cmQ+PGtleXdvcmQ+VGltZSBGYWN0b3JzPC9rZXl3b3JkPjxrZXl3b3JkPipUcmF2ZWw8L2tleXdv
cmQ+PGtleXdvcmQ+VmVub3VzIFRocm9tYm9zaXMvZXBpZGVtaW9sb2d5L2V0aW9sb2d5L3ByZXZl
bnRpb24gJmFtcDsgY29udHJvbDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDAz
PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+RGVjIDgtMjI8L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRl
cz48aXNibj4wMDAzLTk5MjYgKFByaW50KSYjeEQ7MDAwMy05OTI2IChMaW5raW5nKTwvaXNibj48
YWNjZXNzaW9uLW51bT4xNDY2MjYzMTwvYWNjZXNzaW9uLW51bT48dXJscz48cmVsYXRlZC11cmxz
Pjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L3B1Ym1lZC8xNDY2MjYzMTwvdXJsPjwv
cmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuMTAwMS9hcmNo
aW50ZS4xNjMuMjIuMjc2NjwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PGxhbmd1YWdlPmVuZzwv
bGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT5=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZXJlei1Sb2RyaWd1ZXo8L0F1dGhvcj48WWVhcj4yMDAz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ADDIN EN.CITE.DATA 7 Therefore, in these patients a thrombophilia screen may be advisable. This patient had proliferative lupus-like nephritis (class III) for which treatment with corticosteroids and mycofenolate mofetil is standard.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HaW56bGVyPC9BdXRob3I+PFllYXI+MjAwNTwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HaW56bGVyPC9BdXRob3I+PFllYXI+MjAwNTwvWWVhcj48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ADDIN EN.CITE.DATA 8,9 This was complicated by pancytopenia. The anti-CD20 monoclonal antibody rituximab (which depletes B cells) is a potential alternative therapy for those patients who have failed with either cyclophosphamide or mycofenolate mofetil.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJlY051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=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJlY051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=
ADDIN EN.CITE.DATA 10,11 Current treatment for antiphospholipid syndrome is lifelong anticoagulation, usually with warfarin. Rituximab is a recognised treatment for catastrophic or refractory antiphospholipid syndrome. ADDIN EN.CITE <EndNote><Cite><Author>Berman</Author><Year>2013</Year><RecNum>2337</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>2337</rec-number><foreign-keys><key app="EN" db-id="wft50wp9xr92tke5tz8pssfv0tw5xwxdwaxv" timestamp="1382708826">2337</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Berman, H.</author><author>Rodriguez-Pinto, I.</author><author>Cervera, R.</author><author>Morel, N.</author><author>Costedoat-Chalumeau, N.</author><author>Erkan, D.</author><author>Shoenfeld, Y.</author><author>Espinosa, G.</author></authors></contributors><auth-address>Department of Autoimmune Diseases, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Catalonia, Spain.</auth-address><titles><title>Rituximab use in the catastrophic antiphospholipid syndrome: Descriptive analysis of the CAPS registry patients receiving rituximab</title><secondary-title>Autoimmun Rev</secondary-title><alt-title>Autoimmunity reviews</alt-title></titles><periodical><full-title>Autoimmun Rev</full-title><abbr-1>Autoimmunity reviews</abbr-1></periodical><alt-periodical><full-title>Autoimmun Rev</full-title><abbr-1>Autoimmunity reviews</abbr-1></alt-periodical><pages>1085-90</pages><volume>12</volume><number>11</number><edition>2013/06/20</edition><dates><year>2013</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1873-0183 (Electronic)
1568-9972 (Linking)</isbn><accession-num>23777822</accession-num><urls><related-urls><url> complicates ~5% of all patients undergoing renal biopsy.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3JhcGk8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3JhcGk8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxS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ADDIN EN.CITE.DATA 13 Female patients, >40 years old, with a systolic BP >130mmHg are at increased risk. Our patient met all these criteria and was also anticoagulated for likely antiphospholipid syndrome. There are currently no guidelines for management of patients on long-term anticoagulation who are undergoing renal biopsy. In other areas of medicine risk stratification scores quantify the bleeding risk for patients who are anticoagulated.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QaXN0ZXJzPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48
UmVjTnVtPjIzMzg8L1JlY051bT48RGlzcGxheVRleHQ+PHN0eWxlIGZhY2U9InN1cGVyc2NyaXB0
Ij4xNDwvc3R5bGU+PC9EaXNwbGF5VGV4dD48cmVjb3JkPjxyZWMtbnVtYmVyPjIzMzg8L3JlYy1u
dW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ3ZnQ1MHdwOXhyOTJ0a2U1
dHo4cHNzZnYwdHc1eHd4ZHdheHYiIHRpbWVzdGFtcD0iMTM4MjcxMTM2MyI+MjMzODwva2V5Pjwv
Zm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlw
ZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+UGlzdGVycywgUi48L2F1dGhvcj48YXV0
aG9yPkxhbmUsIEQuIEEuPC9hdXRob3I+PGF1dGhvcj5OaWV1d2xhYXQsIFIuPC9hdXRob3I+PGF1
dGhvcj5kZSBWb3MsIEMuIEIuPC9hdXRob3I+PGF1dGhvcj5DcmlqbnMsIEguIEouPC9hdXRob3I+
PGF1dGhvcj5MaXAsIEcuIFkuPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRo
LWFkZHJlc3M+RGVwYXJ0bWVudCBvZiBDYXJkaW9sb2d5LCBNYWFzdHJpY2h0IFVuaXZlcnNpdHkg
TWVkaWNhbCBDZW50cmUsIE1hYXN0cmljaHQsIFRoZSBOZXRoZXJsYW5kcy48L2F1dGgtYWRkcmVz
cz48dGl0bGVzPjx0aXRsZT5BIG5vdmVsIHVzZXItZnJpZW5kbHkgc2NvcmUgKEhBUy1CTEVEKSB0
byBhc3Nlc3MgMS15ZWFyIHJpc2sgb2YgbWFqb3IgYmxlZWRpbmcgaW4gcGF0aWVudHMgd2l0aCBh
dHJpYWwgZmlicmlsbGF0aW9uOiB0aGUgRXVybyBIZWFydCBTdXJ2ZXk8L3RpdGxlPjxzZWNvbmRh
cnktdGl0bGU+Q2hlc3Q8L3NlY29uZGFyeS10aXRsZT48YWx0LXRpdGxlPkNoZXN0PC9hbHQtdGl0
bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Q2hlc3Q8L2Z1bGwtdGl0bGU+PGFi
YnItMT5DaGVzdDwvYWJici0xPjwvcGVyaW9kaWNhbD48YWx0LXBlcmlvZGljYWw+PGZ1bGwtdGl0
bGU+Q2hlc3Q8L2Z1bGwtdGl0bGU+PGFiYnItMT5DaGVzdDwvYWJici0xPjwvYWx0LXBlcmlvZGlj
YWw+PHBhZ2VzPjEwOTMtMTAwPC9wYWdlcz48dm9sdW1lPjEzODwvdm9sdW1lPjxudW1iZXI+NTwv
bnVtYmVyPjxlZGl0aW9uPjIwMTAvMDMvMjA8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFn
ZWQ8L2tleXdvcmQ+PGtleXdvcmQ+QXRyaWFsIEZpYnJpbGxhdGlvbi8qY29tcGxpY2F0aW9ucy9l
cGlkZW1pb2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+RXVyb3BlL2VwaWRlbWlvbG9neTwva2V5d29y
ZD48a2V5d29yZD5GZW1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+Rmlicmlub2x5dGljIEFnZW50cy8q
YWR2ZXJzZSBlZmZlY3RzL3RoZXJhcGV1dGljIHVzZTwva2V5d29yZD48a2V5d29yZD5Gb2xsb3ct
VXAgU3R1ZGllczwva2V5d29yZD48a2V5d29yZD5IZW1vcnJoYWdlLyplcGlkZW1pb2xvZ3kvZXRp
b2xvZ3k8L2tleXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3b3JkPkluY2lkZW5j
ZTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPlBsYXRlbGV0IEFnZ3Jl
Z2F0aW9uIEluaGliaXRvcnMvKmFkdmVyc2UgZWZmZWN0cy90aGVyYXBldXRpYyB1c2U8L2tleXdv
cmQ+PGtleXdvcmQ+UG9wdWxhdGlvbiBTdXJ2ZWlsbGFuY2UvKm1ldGhvZHM8L2tleXdvcmQ+PGtl
eXdvcmQ+UHJvZ25vc2lzPC9rZXl3b3JkPjxrZXl3b3JkPlByb3NwZWN0aXZlIFN0dWRpZXM8L2tl
eXdvcmQ+PGtleXdvcmQ+UmlzayBBc3Nlc3NtZW50LyptZXRob2RzPC9rZXl3b3JkPjxrZXl3b3Jk
PlJpc2sgRmFjdG9yczwva2V5d29yZD48a2V5d29yZD5TdHJva2UvZXRpb2xvZ3kvcHJldmVudGlv
biAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjwva2V5d29yZHM+PGRhdGVzPjx5ZWFyPjIwMTA8L3ll
YXI+PHB1Yi1kYXRlcz48ZGF0ZT5Ob3Y8L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4x
OTMxLTM1NDMgKEVsZWN0cm9uaWMpJiN4RDswMDEyLTM2OTIgKExpbmtpbmcpPC9pc2JuPjxhY2Nl
c3Npb24tbnVtPjIwMjk5NjIzPC9hY2Nlc3Npb24tbnVtPjx3b3JrLXR5cGU+Q29tcGFyYXRpdmUg
U3R1ZHkmI3hEO1Jlc2VhcmNoIFN1cHBvcnQsIE5vbi1VLlMuIEdvdiZhcG9zO3Q8L3dvcmstdHlw
ZT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L3B1
Ym1lZC8yMDI5OTYyMzwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNv
dXJjZS1udW0+MTAuMTM3OC9jaGVzdC4xMC0wMTM0PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48
bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPn==
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QaXN0ZXJzPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48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==
ADDIN EN.CITE.DATA 14 Similar scores may be of help in such complex cases.References ADDIN EN.REFLIST 1.Cameron JS. Lupus nephritis. J Am Soc Nephrol 1999;10:413-24.2.Huerta A, Bomback AS, Liakopoulos V, et al. Renal-limited 'lupus-like' nephritis. Nephrol Dial Transplant 2012;27:2337-42.3.Uthman I, Khamashta M. Antiphospholipid syndrome and the kidneys. Semin Arthritis Rheum 2006;35:360-7.4.Nochy D, Daugas E, Droz D, et al. The intrarenal vascular lesions associated with primary antiphospholipid syndrome. J Am Soc Nephrol 1999;10:507-18.5.Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haem 2006;4:295-306.6.Tektonidou MG, Sotsiou F, Nakopoulou L, Vlachoyiannopoulos PG, Moutsopoulos HM. Antiphospholipid syndrome nephropathy in patients with systemic lupus erythematosus and antiphospholipid antibodies: prevalence, clinical associations, and long-term outcome. Arthritis Rheum 2004;50:2569-79.7.Perez-Rodriguez E, Jimenez D, Diaz G, et al. Incidence of air travel-related pulmonary embolism at the Madrid-Barajas airport. Arch Intern Med 2003;163:2766-70.8.Ginzler EM, Dooley MA, Aranow C, et al. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. New Engl J Med 2005;353:2219-28.9.Chan TM, Li FK, Tang CS, et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. Hong Kong-Guangzhou Nephrology Study Group. New Engl J Med 2000;343:1156-62.10.Lu TY, Ng KP, Cambridge G, et al. A retrospective seven-year analysis of the use of B cell depletion therapy in systemic lupus erythematosus at University College London Hospital: the first fifty patients. Arthritis Rheum 2009;61:482-7.11.Melander C, Sallee M, Trolliet P, et al. Rituximab in severe lupus nephritis: early B-cell depletion affects long-term renal outcome. clin J Am Soc Nephrol i 2009;4:579-87.12.Berman H, Rodriguez-Pinto I, Cervera R, et al. Rituximab use in the catastrophic antiphospholipid syndrome: Descriptive analysis of the CAPS registry patients receiving rituximab. Autoimmun Rev 2013;12:1085-90.13.Corapi KM, Chen JL, Balk EM, Gordon CE. Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Am J Kidney Dis 2012;60:62-73.14.Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010;138:1093-100.Figure legendPanels A & B show images representative of the first kidney biopsy (A) is a low power view of cortex and shows tubular atrophy and interstitial fibrosis. (hematoxylin and eosin; original magnification x100). (B) shows a glomerular segmental scar, a tuft-capsule adhesion and mesangial proliferation (both hematoxylin and eosin; original magnification x400). Panels C-E show images representative of the second kidney biopsy(C) is a low power view of the cortex showing an increase in tubular atrophy and interstitial fibrosis compared to (A) (hematoxylin and eosin; original magnification x100). (D) shows segmental mesangial proliferation. (D) and (E) show an interlobular artery with intimal edema, myointimal proliferation, medial dilation and thinning together representing malignant vascular injury (D: hematoxylin and eosin; original magnification x200; E is a higher power view of D). ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- university of minnesota college of education
- university of minnesota school of social work
- wharton school of the university of pennsylvania
- cost of university of scranton
- university of minnesota school of education
- university of scranton cost of attendance
- university of south florida college of medicine
- university of minnesota masters of social work
- ecampus of university of phoenix
- university of minnesota college of continuing education
- university of illinois college of nursing
- university of north texas college of nursing