ABSTRACT
BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune, multiorgan disease that usually affects young women. The kidneys are affected (lupus nephritis) in close to one fifth of the patients. Over the past decade earlier diagnosis and improved treatment of lupus nephritis has resulted in substantial improvement of renal function and patient survival. Despite these advances, 10 - 15 % of SLE patients with lupus nephritis progress to end-stage renal disease, requiring dialysis or renal transplantation. The article outlines main principles for diagnosing and treating lupus nephritis, according to current practice at Oslo University Hospital. MATERIAL AND METHODS: National and international guidelines (on treatment of lupus nephritis), literature identified through a non-systematic search in PubMed and our own clinical experience form the basis for the article. RESULTS: In lupus nephritis, low-dose cyclophosphamide and corticosteroids are topical treatment for induction therapy, and mycophenolate mofetil is an alternative treatment. We recommend maintenance treatment with azathioprine or mycophenolate mofetil for at least two years. Treatment with rituximab may be considered in patients with refractory lupus nephritis. INTERPRETATION: Subtypes and activity of the renal disease are decisive for choice of treatment.
Subject(s)
Lupus Nephritis , Adrenal Cortex Hormones/therapeutic use , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Murine-Derived , Cyclophosphamide/therapeutic use , Female , Humans , Immunosuppressive Agents/therapeutic use , Kidney/pathology , Lupus Nephritis/classification , Lupus Nephritis/diagnosis , Lupus Nephritis/drug therapy , Mycophenolic Acid/analogs & derivatives , Mycophenolic Acid/therapeutic use , Practice Guidelines as Topic , Prognosis , Recurrence , RituximabABSTRACT
BACKGROUND: Intradialytic morbid events (IMEs) during haemodialysis (HD), including symptomatic hypotension, are related to ultrafiltration (UF)-induced hypovolaemia. Blood volume monitoring and automatic feedback control of the UF rate were developed to limit the extent of hypovolaemia during dialysis. The present study investigated the effect of blood volume (BV)-controlled UF on the incidence of HD treatments with IMEs. METHODS: This prospective randomised crossover study included hypotension-prone patients, characterised by occurrence of IMEs in at least 33% of HD treatments during a 6-week screening phase. These patients underwent 2 treatment phases, each lasting 6 weeks, in randomised order. Each patient served as their own control, treated with standard HD in one phase and with BV-controlled UF in the other phase. RESULTS: Thirty-four patients from 9 HD centres were enrolled; 26 could be included in the analysis population. In comparison with standard HD, BV-controlled UF reduced the percentage of HD sessions complicated by IME significantly from 40%+/-27% to 32%+/-25% (p=0.02). A lower frequency of HD sessions with IME could be observed in 46% of the patients. The frequency of treatments with symptomatic hypotension was reduced from 32%+/-23% in standard HD to 24%+/-21% with BV-controlled UF (p=0.04). Changes in blood pressure and heart rate from start to end of the HD session were not different between the 2 treatment modes. CONCLUSIONS: This crossover study showed improved intradialytic stability with BV-controlled UF, compared with standard HD.
Subject(s)
Blood Volume/physiology , Fluid Therapy/methods , Hypotension, Orthostatic/physiopathology , Hypotension/physiopathology , Hypovolemia/physiopathology , Renal Dialysis/adverse effects , Aged , Blood Volume Determination , Cross-Over Studies , Female , Follow-Up Studies , Humans , Hypertonic Solutions/administration & dosage , Hypotension/etiology , Hypotension/prevention & control , Hypotension, Orthostatic/etiology , Hypotension, Orthostatic/prevention & control , Hypovolemia/complications , Hypovolemia/therapy , Infusions, Intravenous , Isotonic Solutions/administration & dosage , Male , Prospective Studies , Renal Dialysis/methods , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: In industrialised countries the incidence of type 2 diabetes-associated end stage renal disease has doubled over the last ten years. It is important to lower the blood pressure to inhibit progression of renal failure and to prevent micro- and macrovascular disease in these patients. There is an ongoing discussion on what should be the drug of choice. MATERIAL AND METHODS: We discuss the results from three landmark studies, recently published, on the use of angiotensin II antagonists in patients with type 2 diabetics and nephropathy. RESULTS AND INTERPRETATION: All three studies found a renoprotective effect of angiotensin II antagonists that could not be explained by the effect on the blood pressure alone. Blockade of the renin angiotensin system with angiotensin II antagonist should be the basis of treatment in type 2 diabetic nephropathy.
