master

1. Lupus Nephritis
Hussein Sheashaa, MD, FACP
Professor of Nephrology, Urology and Nephrology Center and Director of
Medical E-Learning Unit, Mansoura University, ESNT-CME Chair and Executive
Director of ESNT- Virtual Academy: http://lms.mans.edu.eg/esnt/
GN Master Class, Monday, 21 October, 2019

4.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

6. 2019

7. Curr Opin Rheumatol November 2019, 31:682–688
Lupus Nephritis:
Why?

8. Lupus Nephritis:
Egypt Jan 1980 to June 2016

9.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

10.  Glomerular
 Immune complex glomerulonephritis
 Pauci-immune
 RPGN
 Tubulointerstitial
 Vascular
 APLN
 Vasculitis
 RVT
Renal Pathology:
Spectrum in SLE

11. Lupus (2017) 26, 1228–1234
LN Classes:
What is The Most Common Class?

12. Active Lesions

13. Active Lesions

14. Chronic Lesions (C)

15. IgG

16. Clin J Am Soc Nephrol 11: 585–592, 2016
Lupus Nephritis:
Lupus Podocytopathy

17. Kidney International (April 2018) 93, 789–796
Lupus Nephritis Diagnosis:
Revision of ISN/RPS

18. Pathological Indices
 Activity:
1. Mesangial proliferation
2. Hyaline lesions
3. Cellular crescents
4. Necrosis
5. Neutrophils/ glomerulus
6. Interstitial inflammation
X2
X2
 Chronicity:
1. Sclerotic glomeruli
2. Fibrous crescents
3. Atrophic tubules
4. Interstitial fibrosis
< 25%: 1
25-50%: 2
>50%: 3
AI /24
CI /12

19. Reumatologia 2016; 54, 2: 61–66
Lupus Nephritis:
Biopsy Recommendations

20. Proliferative Lupus N:
Histological Versus Clinical Remission
Nephrol Dial Transplant (2017) 32: 1338–1344
One-third of patients who achieved a complete clinical response
after induction had persistently high histologic activity
62% of patients who had complete histologic remission
on rebiopsy were still clinically active.

21. Lupus Nephritis:
Current Algorithms
Clin J Am Soc Nephrol. 2017 May 8;12(5):825-835.

22. Kidney International 2019, in press
Lupus Nephritis:
Kidney Biopsy to Guide Maintenance IS

23. Q

24.  If the biopsy findings are:
 60% cellular crescents, no necrosis, 70% hyaline
lesions, 70 % mesangial proliferation, 30 % interstitial
inflammation, 20 % neutrophil infiltration,
glomerulosclerosis 10% and interstitial fibrosis 10 %
Q
Calculate AI and CI

25.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

26. Curr Opin Rheumatol November 2019, 31:682–688
Lupus Nephritis:
Predictors of Poor Outcome

27. Curr Opin Rheumatol November 2019, 31:682–688
Lupus Nephritis:
Predictors of Poor Outcome

28. Classification and Reporting of GN
Nephrol Dial Transplant (February 2019) 34: 193–199

29. Lupus Nephritis:
Impact of Antiphospholipid Antibodies
Lupus (2019) 28, 1460–1467
53/149 (35.6%) patients with biopsy-proven LN

30. Medicine (Baltimore). 2017 Sep;96(37):e8024.
LN Outcome Prediction:
Score System
< 10 11-20 > 20 incidences of ESRD in these 3 groups
were 2.7%, 32.5%, and 79.4%,

31.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

33. Treatment of LN:
Principles
 As early as possible
 Aggressive enough to obtain complete remission
 Able to prevent renal flare
 Delay or prevent progression to ESRD
Infection/
MalignancyDisease
Control

34. Treatment of LN:
Standard of Care
J Am Soc Nephrol 27: 2929–2939, October 2016

35. J. Comp. Eff. Res. (2019) 8(13), 1125–1141
Lupus Nephritis:
Tacrolimus

36. Kidney International (2019) 95, 219–231
Voclosporin for LN
(AURA Trial-Phase 2)
versus placebo; *P= 0.046, **P <0.001, +P= 0.20, ++P= 0.026
(Aurinia Renal Response
in Active Lupus With
Voclosporin [AURORA-
Phase 3]

37. Treatment of LN:
Maintenance Therapy

38. Treatment of LN:
Maintenance Therapy

39. Am J Kidney Dis. September 2017;70(3):324-336
Treatment of Proliferative
Lupus Nephritis

40. Immunosuppression
for MN

41. Management of SLE:
2019 EULAR Recommendations
Ann Rheum Dis 2019;78:736–745.

42. Clin J Am Soc Nephrol 11: 585–592, 2016
Lupus Nephritis:
Lupus Podocytopathy

43. Lupus Nephritis:
B-cell Therapy
Nephrol Dial Transplant (2019) 34: 22–29

44. Plasmapheresis

45.  Introduction
 Histopathology and renal biopsy
 Outcome predictors
 Treatment
 Special situations
Outline

46. Treatment of LN:
Pregnancy

47. Lupus Nephritis:
Pregnancy?

48. Refractory Lupus Nephritis:
Management Algorithm
Kidney International (2019) 95, 281–295

49.  When to transplant a lupus nephritis ESRD?
Q

50. Recurrence
Curr Opin Nephrol Hypertens. 2017 Nov;26(6):501-508.

51. Concluding Remarks

52. Treatment of LN:
Algorithm of Treatment

55. ESNT Virtual Academy:
http://lms.mans.edu.eg/esnt/
27831 Users
21 October 2019