It's worth thinking about lupus nephritis.

Author: Zhu Yifeng, this article is authorized by the author to release yimaitong. Please do not reprint without authorization.lupus nephritis (LN) is an important renal complication of systemic lupus erythematosus (SLE).the clinical manifestations of renal involvement include proteinuria, red cell urine, leukocyturia, tubular urine, decreased glomerular filtration function and renal tubular function.the severity of renal damage is closely related to the prognosis of SLE. Renal involvement and progressive renal function damage are one of the main death causes of SLE, which should be paid enough attention to in clinic.case sharing patient Chen, female, 23 years old, visited the hospital on May 19, 2020.chief complaint: edema of face and limbs for 2 days.current medical history: two days ago, there was no obvious inducement for the patient to have facial and limb edema, which was pitted edema. At the beginning, it was the face, and gradually developed to both lower limbs, showing symmetrical distribution. Urine protein 3 + and occult blood 3 + were examined in the hospital.gain 7kg.blood pressure 130 / 80mmHg.the past history, personal history and family history are not special.physical examination: body temperature 36.7 ℃, pulse 80 times / min, breathing 20 times / min, blood pressure 130 / 80 mmHg, moderate edema on the face and face, flaky erythema on the cheek, asymmetric distribution, no percussion pain in both renal regions, and moderate depressed edema in both lower limbs.laboratory examination after admission: urine protein qualitative 4 +; 24-hour proteinuria: 5900 mg / L, urine volume 2100ml, 12.39 g; liver and kidney function + blood lipid: ALB 27.3 g / L, TG 3.19 mmol / L, TC 4.27 mmol / L, GFR 47.94 ml / min, SCR 80.9 μ mol / L.blood routine examination: WBC 2.82 × 10 ^ 9 / L, hepatitis B and vasculitis indicators were negative.antinuclear antibody spectrum: anti SM antibody (-); anti ScL-70 antibody (-), anti j0-1 antibody (-), anti riboprotein P antibody (-), anti U1-snRNP antibody (-), anti dsDNA antibody (weak positive), anti nucleosome antibody (weak positive), anti histone antibody (weak positive), anti centromere B protein antibody (-), anti r052 antibody (+), anti r060 antibody (-), anti SSB antibody （-）。Color Doppler ultrasound: a small amount of ascites in abdominal cavity and pericardial effusion.according to the patient's history, physical examination and biochemical results, is it nephrotic syndrome, but is it primary or secondary? Combined with the above, can SLE be diagnosed? Let's take a look at the diagnostic criteria of SLE: Table 1 diagnostic criteria of SLE. Therefore, according to the patient's history and examination: 1. Young women; 2. Cheek rash; 3. Serous effusion; 4. Leucopenia; 5. Immunological abnormality (weak positive anti dsDNA antibody); 6. Positive antinuclear antibody; 7. Proteinuria.can be preliminarily diagnosed as: 1. Systemic lupus erythematosus; 2. Nephrotic syndrome; 3. Lupus nephritis?. whether the patient is lupus nephritis needs further diagnosis. Table 2 "balance" renal biopsy is the gold standard for pathological diagnosis of lupus nephritis. Since patients have perirenal effusion and have contraindications for renal biopsy, they can only make a definite diagnosis by renal biopsy on a day after improvement. at present, some symptomatic and supportive treatments such as immunosuppression, lipid regulation and anticoagulation are temporarily given. through the above cases, we can know how to think about the relationship between SLE and nephrotic syndrome, and better understand the clinical thinking of lupus nephritis diagnosis. treatment according to the Chinese guidelines for the diagnosis and treatment of lupus nephritis, we will understand the main principles of diagnosis and treatment [1]: ➤ treatment principle: the treatment of LN needs long-term treatment from induction to maintenance. induction therapy should be individualized and the maintenance treatment time should be at least 3 years after complete remission. regular follow-up is needed during the treatment to adjust the drug dosage or treatment plan, evaluate the curative effect and prevent complications. the ultimate goal of LN treatment is to improve the long-term survival rate of patients and kidneys and improve the quality of life. ➤ evaluation of treatment response: regular follow-up is required during ln treatment to evaluate the treatment response and recurrence of kidney and SLE. ➤ basic treatment: unless there are contraindications, hormone and hydroxychloroquine sulfate (HCQ) should be used as the basic drugs for the treatment of LN. ➤ selection of immunosuppressive regimen: renal pathological type and pathological activity are the basis for the selection of LN treatment scheme, and the induction and maintenance treatment scheme for LN with different pathological types are different. the treatment regimen and dosage should also be individualized according to the patient's age, nutritional status, liver function, infection risk, renal injury indicators (such as urinary protein quantification, urinary sediment and SCR level), extrarenal organ damage, fertility intention, complications, and the treatment response of previous immunosuppressants. at present, some scholars have compared the current four schemes: simple hormone (P), hormone + mycophenolate mofetil (P + MMF), hormone + immunosuppressant cyclophosphamide (P + CTX), and hormone single shock + cyclophosphamide (PSP + CTX). The results show that the safety and effectiveness of hormone + mycophenolate mofetil (P + MMF) are higher [2]. Li and other studies have shown that MMF is superior to the traditional cyclophosphamide regimen in the treatment of LN in active phase, and MMF makes the clinical treatment strategy of LN more effective and diversified [3]. some scholars have also conducted meta-analysis and found that in the active stage of LN, on the basis of simple western medicine treatment, the traditional Chinese medicine treatment of clearing heat, detoxification, nourishing yin and lowering fire can reduce the occurrence of toxic and side effects of Western medicine; while in the remission stage of LN, the synergetic treatment of traditional Chinese medicine such as nourishing Yuan Yin and Yuan Yang, supplementing qi and warming the kidney, can help to reduce the hormone used, effectively reduce the recurrence rate, and thus reduce the recurrence rate The curative effect of solid therapy. the treatment of LN with integrated traditional Chinese and Western medicine well reflects the individualized treatment, which is conducive to the treatment and rehabilitation of patients, and has the opportunity to delay the progress of end-stage renal disease [4]. References: [1]. Guidelines for diagnosis and treatment of lupus nephritis in China [J]. Chinese Journal of medicine, 2019 (44): 3441-3455. [2] Wang Hong, Yang Lei. Analysis of the efficacy and safety of common treatment schemes for lupus nephritis [J]. Journal of clinical rational drug use, 2019, 12 (24): 126-127. [3] Li x, Ren h, Zhang Q. mycophenolate mofetil or tacrolimus compared with [4] Chen Benli, Yuan Shuo, Huang Guodong. Meta analysis of lupus nephritis treated with integrated Chinese and Western Medicine [J]. Hunan Journal of traditional Chinese medicine, 2017, 33 (03): 130-133