Clinical Briefing:
Interdisciplinary Management of Glomerulonephritis
November/December 2007
At Penn's Renal-Electrolyte and Hypertension
Division,
the effective clinical
management of glomerular disease is directed at abating the
acute manifestations of
kidney disease, protecting kidney function, and managing
symptoms of renal and nonrenal
disease.
These objectives are achieved through the interdisciplinary
collaboration
of nephrologists, immunologists, pathologists, rheumatologists,
and others. The
coordination of care between these various specialties ensures
that the intricacies of
management, which are so profoundly affected by the patient's
clinical characteristics
and comorbidities, are effectively addressed.
Kidney biopsy showing a glomerulus
with diffuse cellular
proliferation occluding the capillary loops.
Original magnification
X25. |
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Penn's multidisciplinary
approach also allows its physicians to orchestrate the
intricate balance between immunosuppressive and cytotoxic
drug therapy, antihypertensive medications,
and other therapies used to treat the disease and its effects,
and when appropriate,
provide for optimally timed renal replacement therapy, whether
in-center hemodialysis,
home dialysis, or transplantation.
Case Study
Ms. K, a 23-year-old woman, was referred with 6 weeks of
lower extremity edema,
facial rash and arthralgias. She had a BP of 160/95 mmHg.
A urinalysis had 3+ protein
and 1+ blood; dysmorphic RBCs and granular and rare RBC casts
were evident. A
24-hour urine collection had 2.1 g of protein. Ms K's
Hgb level was 9.9 g/dl; platelet
count was 110,000; serum
creatinine (Cr) was 1.8 mg/dl.
Additional
workup revealed
positive ANA, elevated anti-dsDNA Ab and hypocomplementemia.
A percutaneous
renal biopsy demonstrated diffuse proliferative glomerulonephritis.
A repeat Cr was
2.7 mg/dl. Ms. K was diagnosed with SLE and stage IV (WHO)
lupus nephritis.
“Acute glomerulonephritis is
generally marked by a significant
decline in kidney function, and is
often associated with serious
systemic complications affecting
multiple organs. To ensure effective
management, it is essential that the
clinical environment include the
ability to undertake prompt
institution of a coordinated,
systemic approach to diagnosis and
treatment that encompasses the
capacity to shift medications and
treatment direction when necessary
and the ability to manage multi-system disease
manifestations when they develop.”
– Jeffrey S.
Berns, MD
Associate Chief for Clinical Affairs;
Director,
Renal Fellowship Program |
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Treatment with intravenous methylprednisolone
followed by oral prednisone and intravenous
cyclophosphamide brought rapid improvement of her symptoms.
Alendronate
with calcium supplementation was introduced as part of a
comprehensive treatment
plan coordinated with the Division
of Rheumatology.
At six
months, Ms. K began
mycophenolate mofetil (1.5 gm b.i.d.); cyclophosphamide was
discontinued. Her urine
protein at this time was <200 mg/24 h, her Cr was 0.9
mg/dl and her serum complement
levels had nearly normalized.
Five months later, however,
Ms. K reported an increase
in arthralgias. Her proteinuria had increased to 1.4 gm/24
h, her Cr was increased
to 1.7 mg/dl, and her C3 and C4 complement levels were again
low, with an increase
in anti-dsDNA Ab titer. After discussions with Ms. K and
her rheumatologists,
treatment with the anti-CD20 antibody rituximab (375 mg/m2
weekly) was initiated.
Ms. K reported no active symptoms of
lupus after three once-weekly doses. Over
the next few months her Cr declined to 0.6 mg/dl, and her
proteinuria fell to <100 mg/24 h. She has remained stable
without recurrence of her lupus manifestations.
Our Team of Faculty
The faculty of the Penn Renal-Electrolyte and Hypertension
Division offers
diagnostic evaluation and clinical management for patients
with acute or chronic
kidney diseases, renal failure, acute glomerulonephritis,
complex hypertension,
diabetic nephropathy, nephrotic syndrome, amyloidosis, electrolyte
and acid-based
disturbances, genetic kidney diseases, hematuria, proteinuria,
and kidney stones.
Patient care is provided in a setting with access to a full
array of multidisciplinary
state-of-the-art clinical and diagnostic services.
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Referring Physicians: To speak with a Penn physician
or refer a patient, contact PennHealth through the secure online
referral form or by calling
1-800-789-PENN
(7366). |
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