A 25-year-old woman is evaluated during a routine follow-up visit. Four months ago, she was diagnosed with systemic lupus erythematosus that manifested as fatigue, malar rash, oral ulcers, pleuritis, and arthralgia. At that time, she began treatment with hydroxychloroquine and a 1-month course of low-dose prednisone.
On physical examination today, she states that her symptoms have resolved somewhat but that she still has slight fatigue and mild arthralgia in her hands, feet, and knees. Temperature is 36.4°C (97.6°F), blood pressure is 130/92 mm Hg, pulse rate is 84/min, and respiration rate is 18/min. She has a mild malar flush, a painless ulcer on the hard palate, and trace bilateral ankle edema. The remainder of the examination is normal.
||10 g/dL (100 g/L)
||2300/µL (2.3 × 109/L)
||132,000/µL (132 × 109/L)
|Erythrocyte sedimentation rate
||1.0 mg/dL (88.4 µmol/L)
||3.1 g/dL (31 g/L)
|Serum complement (C3 and C4)
||2+ protein; 3+ blood; 5-10 leukocytes, 15-20 erythrocytes, and 1 erythrocyte cast/hpf
This patient's hypertension, ankle edema, hematuria, proteinuria, hypoalbuminemia, and erythrocyte casts on urinalysis are highly suggestive of lupus nephritis despite the absence of renal insufficiency. To prevent irreversible renal damage, early treatment with a high-dose corticosteroid such as prednisone is indicated for patients whose condition raises strong suspicion for lupus nephritis. Whether renal biopsy is necessary in this clinical situation in order to establish a diagnosis remains uncertain, and treatment with high-dose corticosteroids would not significantly alter subsequent biopsy results.
Initiation of antihypertensive therapy would benefit this patient but is not the most appropriate next step in the management of her condition; treatment of her nephritis takes precedence and may itself help to control her hypertension. Instead of a calcium channel blocker such as amlodipine, angiotensin-converting enzyme inhibitors are the antihypertensive drugs of choice in patients with lupus nephritis because these agents help to control proteinuria.
Ibuprofen may help to control this patient's arthralgia. However, NSAIDs can significantly worsen renal function in patients with lupus nephritis and are therefore contraindicated in this patient population.
Low-dose prednisone may help to alleviate this patient's arthralgia and rash but would not treat her lupus nephritis.
- Early treatment with high-dose corticosteroids is indicated in patients whose condition raises strong suspicion for lupus nephritis.