Classification of Lupus Nephritis

According to ISN/RPS, Lupus Nephritis can be divided into the following types roughly. And, there are also many further classifications of lupus nephritis, but I did not mentioned here.
Class I. Minimal mesangial lupus nephritis: normal glomeruli under light microscope, but with minimal mesangial deposits in immunofluorescence.
Class II. Proliferative mesangial lupus nephritis: hypercellularity and mild mesangial expansion under light microscope, with mesangial deposits evident
in immunofluorescence; there may be subepithelial or subendothelial deposits visible in an electron microscope or with immunofluorescence.
Class III. Focal lupus nephritis: lesions present in <50% of glomeruli with endo or extracapillary lesions, subendothelial deposits, with or without mesangial involvement. There may be active (A) or chronic (C) lesions, leading to the subdivision into:
- Class III (A): active lesions (focal proliferative lupus nephritis)
- Class III (A/C): active and chronic lesions (focal and sclerosing proliferative lupus nephritis)
- Class III (C): inactive chronic scarring lesions (focal sclerosing lupus nephritis)

Class IV. Diffuse lupus nephritis:lesions in >_50% of glomeruli with diffuse subendothelial deposits, with or without mesangial alterations. May have A or C lesions. In addition, the lesions may be segmental or global.

how to monitor SLE in routine clinical practice

SLE(systematic lupus erythmatosus) is a multisystem autoimmune rheumatic disease. The clinical manifestations of the disease are diverse, often complex, and results from inflammation in a variety of organs. Patients may present to a variety of specialists owing to the variable clinical and serological expression of disease.
Laboratory measures can be used to assess disease activity and damage. We recommend that the following procedures should be performed at each clinic visit.
Full blood count(FBC) and white cell differential to assess anaemia, neutropenia, leucopenia, lymphopenia, and thrombocytopenia. It is important to remember that haematological abnormalities maybe due to concomitant drug treatment, in particular, with cyclophosphamide, which lowers the white blood cell count, and azathioprine, which often increases the mean corpuscular volume but rarely causes a pancytopenia.
Erythrocyte sedimentation rate(ESR) paired with C reactive protein may help to distinguish lupus flare from infection, in which one would expect a raised ESR and CRP in the latter. However, sometimes, CRP maybe raised in patients with intercurrent infections, serositis, or erosive arthritis.
Urea ans serum creatinine, although these tests are often normal. A rapid rising urea and/or creatinine implies that renal activity is 'turning into' damage.
Liver function tests are mandatory in patients receiving particular disease modifying antirheumatic drugs. They may be deranged secondary to non-steroidal and anti-inflammatory drugs or autoimmune liver disease.
Urine analysis for red and white cells, protein, and cellular casts are useful tests of renal activity and may reveal clinical silent renal disease. If any of these analysis are abnormal and especially if serial tests are increasingly abnormal further investigations including a 24 hours urinary protein estimation or the often preferred protein/creatinine ratio estimation, and , and creatinine clearance rate should be taken together with a renal ultrasound.
Antinuclear antibodies(ANA) are positive in more than 95% of patients with lupus. Anti-double stranded DNA(dsDNA) antibodies are positive in about 60% of these patients and can be detected by immunofluorescent crithidia testing, ELISA, or radioimmunoassay. Antibodies to dsDNA may fluctuate with disease activity in many patients, but not in all.
Other routinely available autoantibodies have not been demonstrated to be helpful as markers of lupus activity. They may, however, be associated with lupus subsets. Anti-Roantibodies, for example, are linked to photosensitivity, subacute cutaneous lupus, and the neonatal lupus syndrome. Anti-La antibodies are associated with concomitant Sjogren's syndrome. Antiphospholipid antibodies often correlate with an increased risk of thrombosis, spontaneous miscarriage, or livedo reticularis. These antibodies are identified in the form of anticardiolipin antibodies, a positive 'so-called' lupus anticoagulant test, or anti-β2-glycoprotein I antibodies.

How Does Lupus Nephritis Happen?

Lupus Nephritis which is a kind of immunological disease refers to SLE complicated with obvious clinical symptoms of kidney damage. This is a traditional diagnosis from the viewpoint of histology. However, from cytology viewpoint which is the modern prognosis, Lupus Nephritis should be called Lupus Glomerular Capillary Epithelial Cells Disease, which means there is pathological change in epithelial cells of glomerular capillary due to lupus factor activity.
When human body is infected by lupus factor, abnormal immune reaction will be caused continuously, which can result in pathogenic autoantibody. Due to this reason, large quantity of immune complex, such as C3, IgG or IgM will deposite in epithelial cells of glomerular capillary, causing immune mediated damage to epithelial cells of glomerular capillary. As a result, these epithelial cells can not work normally to play their function of negative charge barrier. When this barrier function is declined, protein in blood with negative charge will leak out to urine and will be discharged out of body with urine. If patients go to hospital for a urine test in this period, the result of protein positive will be tested out. From the above, it can be found that Lupus Nephritis actually is caused by the damage to epithelial cells of glomerular capillary and related symptoms also occur due to this reason. In another word, the disease actually refers to the damage in epithelial cells, but the symptoms refer to protein or blood positive, edema, or other discomforts patients may feel. And then, we say Lupus Nephritis occurs.

Can Lupus Nephritis Patients Get Pregnant?

Lupus Nephritis has a high occurrence rate among women who are at childbearing age. Therefore, the question whether Lupus Nephritis patients can get pregnant or whether they can have a baby is more frequently asked by female Lupus Nephritis patients. Lupus Nephritis patients always have declined kidney function and they also need to take medicines for a long period, so patients always worried about the safety of the baby as well as the prognosis of this disease. However, if the disease can be controlled well, it is possible for Lupus Nephritis patients to have a baby and they can still enjoy the happiness of being a mother.
Lupus Nephritis is easy to relapse, which is also a big problem of being pregnant, but related research showed that Lupus Nephritis patients can get pregnant if they have normal blood pressure and relative normal kidney function, but have no fever of undetermined origin, no polyarthritis and no facial rash, etc. Besides, no protein in urine test for one year and no medication of cytotoxic drug are also necessary requirement for Lupus Nephritis patients who want to have a baby. What’s more, a happy mood and sufficiency energy as well as good appetite are also very important to promise a healthier and better pregnancy, which is helpful for make the baby safe.
However, Lupus Nephritis patients still need to get the agreement of both gynecologist and urologist. With the help and guidance of doctors, Lupus Nephritis patients will be much easier to have a safer pregnancy.
Lupus Nephritis will affect all blood vessels in body which also include placenta and uterus. If lupus factors turn active in this period, it will be easy to cause stillbirth or placental abruption. For this reason, patients who are pregnant are suggested to come to hospital for regular check every two weeks. All the pregnancy duration as well as two months after childbirth should be closely observed by doctors so that timely measures can be taken according to patients’ condition.

Daily Care for Lupus Nephritis Patients

Besides effective treatment, proper daily care is also very important for Lupus Nephritis patients to maintain their condition stable. Well then, what should Lupus Nephritis patients pay attention to?
Firstly, food that is can increase light sensitivity should be avoided, such as fig, milk vetch, rape, celery, etc. If patients take such food occasionally, they should stay in the room in order to avoid sunshine. Besides, mushroom, champignon as well as other similar food or tobacco also have the possibility of inducing and worsening SLE, thus affecting Lupus Nephritis.
Secondly, enough high-quality protein intake is necessary. Large quantity of protein will leak out with urine due to Lupus Nephritis, which is easy to cause hypoproteinemia. Therefore, Lupus Nephritis patients should take enough high-quality protein in order to maintain normal body activity. Food such as milk, eggs, lean meat and fish will be good choice for Lupus Nephritis. However, proper quantity intake is important because too much protein intake can burden kidneys at the same time. Normally, doctors will offer special advice to Lupus Nephritis patients for their protein intake.
Thirdly, infection should be avoided strictly in daily life. Due to Lupus Nephritis, patients need to take immunosuppressant or steroid to control their illness condition, but these medicines have some side effects to the body at the same time. Long term medication of such medicine will make patients have a lower immunity. Therefore, Lupus Nephritis patients will be easy to be infected after long-term of medication.
Fourthly, Lupus Nephritis should have test on their blood sugar regularly. Lupus Nephritis patients need to take glucocorticoid for a long period, which is easy to cause steroid diabetes, so Lupus Nephritis patients should control their intake of food that contains more sugar and test their sugar level regularly.
Besides, a low-salt diet as well as proper calcium supplement is also helpful. Some patients will feel depressed when they are diagnosed as Lupus Nephritis. However, they should keep a happy mood which is helpful for their body. If effective treatment is taken and proper daily life is kept, the disease can still be controlled well and patients can live a normal life.

Treatment for Lupus Nephritis

Basically, treatment for Lupus Nephritis patients should be based on clinical symptoms, laboratory results as well as renal biopsy results. According to the severity of the illness condition, different treatment or medicine will be chosen. Some common medicines include glucocorticoid, NSAID, antimalarial, cytotoxic agents and anticoagulant as well as Chinese Medicine, etc. Besides, all the effect of treatment and medicine should also includes the effect on kinds of complications or side effects from medicines, etc. Therefore, the treatment and medicine prescription for each patient will be specialized and individual. Among all the methods, glucocorticoid is the most common one.
As for patients with slight illness condition, the treatment is mainly chosen based on the symptoms out of kidney and NSAID as well as antimalarial is commonly used. Some Chinese medicine immunosuppressant such as Common Threewingnut Root is also suggested due to its effect on reducing protein and blood in urine as well as its less side effect.
For patients with more serious proteinuria which has got to the degree of Nephrotic Syndrome, hormone dosage should be increased. Normally treatment effect can be found in 4 to 6 weeks. However, if patients who are not sensitive to hormone has already had kidney function decline and serious hypertension, hormone dosage should be reduced, but cytotoxic agents will be added, such as cyclophosphamide.
If patients have acute progressive illness condition and their kidney function declines sharply, dialysis should be considered under such condition in order to keep the safety of the patients.
Sometimes, renal biopsy is helpful for doctors to have a better idea about patients illness condition and to get a rough idea about the prognosis, which is helpful to adjust the treatment schedule and medicine prescription in order to get a better treatment effect.

Why Lupus Nephritis Patients Are Suggested to Take Renal Biopsy

According to clinical experience and research, Lupus Nephritis experts in China pointed out that there are five kinds of pathogenesis category among Lupus Nephritis patients, and patients with different pathogenesis category will also have different reaction to hormone or immunosuppressant. Therefore, doctors will always suggest renal biopsy to Lupus Nephritis patients in order to make sure about the pathogenesis, which is helpful for doctors to adjust for a more effect treatment schedule.
Normally, Lupus Nephritis can be diagnosed by medical history, body sign as well as laboratory test results and routine urine test is always suggested firstly. If SLE patients are found abnormal results through urine test which indicate to kidney problem, Lupus Nephritis will be considered at first, and in this condition, renal biopsy will be suggested. However, if urine test is normal, doctors seldom suggest renal biopsy to SLE patients.
Most of the time, considering the tiny damage that renal biopsy may bring to kidney, doctors always prefer to suggest renal biopsy when Lupus Nephritis patients are not sensitive to their present treatment and medicine or the treatment effect is not as good as they expect, which is helpful for doctors to have further idea about the disease and then doctors can adjust the treatment or medicine in order to get a better treatment effect.

Harms of Lupus Nephritis

Lupus Nephritis which belongs to Secondary Glomerulonephritis is a kind of Autoimmune Diseases. If SLE or Systemic Lupus Erythematosus has involved to kidney can cause obvious kidney damage, we will call this as Lupus Nephritis under such condition.
Presently, more than 70% patients who are diagnosed as the disease of SLE are having kidney damage and nearly 100% SLE patient will have pathological change in their kidney through renal biopsy.
Lupus Nephritis is a most common secondary kidney disease, with main clinical symptoms of proteinuria, haematuria, cylindruia or even renal failure. Lupus Nephritis plays a very important role in the prognosis of SLE patients and it is considered as one of the main death cause of SLE patients. According to the statistics, the surviving rate after 10 years of SLE patients who do not have obvious kidney damage can reach to 90%, but this number will lower to 70% for SLE patients who have Lupus Nephritis. Due to the limitation of present treatment method, renal failure caused by Lupus Nephritis has never been lowered in recent 30 years and patients have to maintain their life by dialysis or kidney transplant, which lowers patients living quality greatly.

Can Chinese Medicine Be Used to Treat Lupus Nephritis?

Can Chinese Medicine Be Used to Treat Lupus Nephritis? More and more Lupus Nephritis patients begin to be tired of endless medication of western medicine to control their disease due to the side effects of western medicines, such as fat, bone problem, acne, gastrointestinal discomforts, etc. What’s more, frequently appeared proteinuria or other related symptoms is also a big problem. Therefore, Chinese Medicine treatment which is a kind of natural treatment starts to get more attention from Lupus Nephritis. However, how about the answer to this question? Is it effective in treating Lupus Nephritis?
The answer is absolutely positive. Based on its thousands years of history, Chinese Medicine plays a more important role in treating various kinds of disease, including Lupus Nephritis. Different from western medicine treatment, Chinese Medicine do not treat only the symptoms, but also the root cause of the disease. For example, proteinuria is a common symptom for Lupus Nephritis patients. Traditionally, some hormone medicines will be taken to reduce the protein by inhibiting the abnormal immune action. However, if patients stop taking medicine, abnormal immune reaction will be active again, which is also the reason of frequent relapse. Chinese Medicine also treat the symptoms during the treatment, but at the same time it also treat Lupus Nephritis from the viewpoint of wholism, which means it will try to find the root cause as well as even tiny difference between each patients, and then Chinese doctors will make the prescription for each patient.
Basically, the functions of Chinese Medicine in treating Lupus Nephritis can be explained in the following aspects: the first one is to activate blood circulation which can offer enough blood flow to kidneys, thus providing a better environment for kidneys and reliving the condition of renal ischemia and anoxia caused by damage in kidney. The second one is to anti-inflammation. Due to the damage from lupus factor, there must be inflammatory reaction in kidney, which is the main cause of kidney damage progressing further. Therefore, stopping the inflammatory reaction is a very important point to prevent further damage. The third one is to degrade and discharge the immune complex deposite in blood and kidney cells, thus the damage caused by such deposite can be relived. Besides, with more blood flow going through kidney, more oxygen and nutrition can get to kidney, which can provide a favorable environment for kidney to repair itself. After a systematic treatment, not only kidney condition, but also patients’ body condition can have a general improvement, which can increase body resistance to external factors, thus reducing the relapse.
Another point should be mentioned is that the prescription of Chinese Medicine is different to each patient even though they are having the same disease. Even according to different understanding on patients’ condition, different Chinese doctors will offer different prescriptions even to the same patient. But no matter what prescription is made, the main function or the aim is the same as this article mentioned above. I think this is just the amazing and magic point of Chinese Medicine, but this is also a big confusion to doctors in other countries.

Traditional Treatment for Lupus Nephritis

Traditionally, western medicines are commonly used to treat Lupus Nephritis due to the fast and high effect. However, no matter what kind of treatment is taken, the aim is the same that is to inactivate lupus factor and relieve the discomforts brought by this disease.
Patients with light SLE but with immunoserology abnormality can choose NSAID medicine to relieve clinical symptoms if their urine test results is relative normal and glomeruli is also normal or only have slight damage through biopsy results. In this case, glucocorticoid or cytotoxic agents is not commonly used, but regular and close observation on the illness condition is necessary. If there is abnormal item in urine test results, and there are also glomeruli focal segmental membrane proliferation as well as segmental necrosis and crescent, glucocorticoid in small or middle dosage can be taken and cytotoxic agents can also be taken rationally.
For patients with serious SLE accompanied by acute nephritis syndrome or progressive nephritis syndrome, standard hormone treatment as well as CTX or Methylprednisolone should be taken if diffusive proliferative glomerulonephritis or crescentic glomerulonephritis, accompanying with kidney function progressive decline can be found. If the above method is not so effective, plasmapheresis should be considered. If acute renal failure or hear failure occur, dialysis is necessary for patients to save their life.
Immunoadsorption is a good method to for Lupus Nephritis patients, which can also relieve related symptoms effectively. According to different individual body condition and illness condition, the treatment will also be different to each other in order to make sure each patient can get a relative good effect. Since there is damage in kidney for Lupus Nephritis patients, kidney function will also decline. Therefore, when Lupus Nephritis patients choose medicine, they should follow doctor’s advice closely.

Commen Introduction of Lupus Nephritis

Lupus Nephritis means there is damage in kidney due to SLE (Systemic Lupus Erythematosus) which is a kind of immune system disease and can involve to all body system. Not all SLE patients will have symptoms of kidney disease, but nearly all SLE patients will have pathological damage in kidney if renal biopsy was done. However, if patients begin to have symptoms related to kidney damage, it means the kidney damage has progressed into a further stage.
Clinically, Lupus Nephritic is one of the most common secondary kidney diseases, especially for female patients. Due to the primary cause, SLE, the symptoms of Lupus Nephritis also involve the whole body system, such as skin rash, joint pain, proteinuria, edema, etc.
Skin problem: more than 80% patients will have skin problem, such as erythema, rash, etc, mainly in face, neck as well as arms and legs. A few patients may also have bleb or bloody vesicle. Besides, about one third patients are too sensitive to light and their face or skin will become red or even have skin rash after exposed under sunshine.
Pain in joints and muscle: more than 90% patients will have swelling and pain on joints, which is also one of the first symptoms. Figure joints are most commonly to be involved. Besides, knee, feet, ankle as well as wrist can also be related. A tiny part of patients may even have joint deformity. Besides, muscle soreness and fatigue are also common symptoms.
Gastrointestinal discomforts: some patients may feel uncomfortable on their stomach and upper gastrointestinal hemorrhage as well as hemafecia and ascetic fluid which is caused by vasculitis of gastrointestinal tract always happens.
Pathological damage of nerve system: about 20% Lupus Nephritis patients will have problems on nerve system which means the disease has already progress further and the illness condition is more severe. Excitement, abnormal behavior, depression as well as illusion or mental disorder may occur.
Heart problem: nearly 10% to 50% patients will have heart problem which is caused by both the disease and long-term medication of glucocorticoid. Some patients may even die from Coronary Artery Obstruction due to this disease.
Symptoms related to kidney: Nearly 100% SLE patients have pathological damage in kidney through biopsy, but not all patients will have related symptoms of kidney damage. About 50% patients will have related clinical symptoms of kidney disease, such as proteinuria, hematuria, cylindruia, leucocyturia, swelling and high blood pressure as well as increasing creatinine and urea, etc.
Besides, the disease can also affect liver function, lung function as well as blood system. Due to the primary disease, Lupus Nephritis patients always have the symptoms that SLE patients also have, but symptoms related to kidney damage are very important indication for SLE patients to have a high awareness on their kidney condition. An early detection is very important for Lupus Nephritis patients to live a higher quality life.