Types of lupus nephritis exacerbations: prognostic significance

AIM: To characterize the course of lupus nephritis (LN) in terms of demographic indices (sex, age of renal disease onset), the presence of antiphospholipid syndrome (APS) and to ascertain a prognostic role of the disease exacerbations. MATERIAL AND METHODS: A total of 121 LN patients were followed up from 1997 to 2004 (mean duration of the follow-up 5.6 +/- 6.4 years). A LN course was characterized by the presence of a complete or partial remission, exacerbation of the disease, repeated hospitalisations. Two types of exacerbations were considered: proteinuric, running with progressive proteinuria and normal renal function (type 1); functional, running with elevation of blood creatinine (type 2). RESULTS: Exacerbations were observed in one third of the examinees, 70% of them ran with renal dysfunction. Exacerbations occurred more frequently in males than in females (50 vs 27%, respectively; p = 0.08) and in patients with early onset of LN (at the age of 40 years and younger, 80 vs 60%, respectively; p < 0.05). Exacerbations of type 2 occurred in males, in patients with early onset of renal damage and in APS association. It is shown that LN exacerbations, their incidence and type (a functional type) have a negative influence on renal survival of the patients. CONCLUSION: Identification of groups of LN patients at high risk of exacerbations and unfavourable prognostic role of exacerbations dictates the necessity of due immunosuppressive therapy for maintenance of remission.     

Clinical and morphological characteristics of lupus nephritis in systemic lupus erythematosus with antiphospholipid syndrome

AIM: To ascertain clinical and morphological features of lupus nephritis (LN) in systemic lupus erythematosus (SLE) associated with antiphospholipid syndrome (APS). MATERIAL AND METHODS: Immunological markers of SLE and APS, clinical picture, urine indices were examined in 138 patients with SLE, APS and renal dysfunction. RESULTS: LN associated with APS is characterized with marked arterial hypertension, such patients had arterial thromboses more frequently than patients with isolated LN. Patients with anticardiolipin antibodies have arteriolosclerosis, in APS - diffuse interstitial sclerosis. CONCLUSION: Renal impairment in SLE may run not only with LN but also with thrombotic microangiopathy modifying clinical symptoms and course of the disease.     

子宫动脉频谱形态异常可预测系统性红斑狼疮患者的妊娠结局

目的探讨子宫动脉多普勒在预测系统性红斑狼疮（SLE)合并妊娠母胎结局中的应用价值。方法回顾性选取45例系统性红斑狼疮合并妊娠孕妇,分析两组患者的临床情况及新生儿结局,并根据子宫动脉多普勒频谱是否出现切迹、搏动指数（PI)值增高,将患者分为正常组（n=31)及异常组（n=14),比较两组间的差异。结果45例孕妇中,15例（33%)出现子痫前期、狼疮性肾炎及抗磷脂综合征,胎儿出现不良结局共9例（20%)。子宫动脉频谱正常组31例（69%),5例（11%)孕妇发生子痫前期,1例（2%)胎儿发生小于胎龄儿。子宫动脉频谱异常组14例（31%),10例（22%)孕妇出现并发症,包括子痫前期、狼疮性肾炎,抗磷脂抗体（+)及抗磷脂综合征;8例（18%)胎儿发生不良结局：包括小于胎龄儿、胎儿生长受限及胎儿丢失。3例（7%)妊娠期新发SLE患者,孕妇子宫动脉波形均出现异常（波形出现切迹、PI值增高),3例胎儿均于围生期死亡。子宫动脉波形异常组母体并发症及胎儿不良结局的发生率均高于波形正常组,组间差异有统计学意义（P < 0.01)。结论孕妇子宫动脉频谱形态异常是预测妊娠期SLE加重及胎儿发生不良结局的敏感指标。     

妊娠合并系统性红斑狼疮孕妇的妊娠时机及对妊娠结局的影响（附25例临床资料分析）

目的：探讨影响妊娠合并系统性红斑狼疮（SLE）妊娠结局的相关因素,提出SLE患者最佳受孕时机和孕期的治疗监护,预防妊娠合并SLE的恶化及SLE对妊娠的不良影响,以提高围产质量。方法回顾性分析25例妊娠合并SLE的临床资料。结果25例妊娠合并SLE患者,14例病情处于缓解期或控制期的患者,仅1例双胎妊娠发生早产,新生儿窒息0例,1例孕妇狼疮性肾炎加重,子痫前期0例;11例病情未控制或有SLE活动者,发生早产4例,新生儿窒息2例,孕期发生狼疮性肾炎3例,血小板减少3例,子痫前期2例。结论SLE患者应首先控制疾病的活动,在产科医师及风湿免疫科医师的指导下受孕,妊娠期加强胎儿监护及SLE疾病的监测、治疗。泼尼松是目前安全可靠的妊娠期治疗及预防SLE恶化、控制SLE活动的首选药物。SLE孕妇应加强孕期的监护,争取良好的妊娠结局。     

Lupus nephritis as a factor of atherosclerosis risk in patients with systemic lupus erythematosus

AIM: To investigate early atherosclerosis (AS) risk factors in patients with systemic lupus erythematosus (SLE) in respect to the presence of lupus nephritis (LN) and antiphospholipid (APL) antibodies. MATERIAL AND METHODS: We analysed case histories of 137 SLE patients observed in E.M. Tareev clinic from 1970 to 2006. AS manifestations were studied by echocardiography, ultrasonic dopplerography of the peripheral vessels, x-ray methods. AS was considered early if it arose at the age under 55 years. Patients with chronic renal failure were not included in the study. RESULTS: AS development was seen in 54 (45%) patients, early symptoms appeared at the age of 25-68 years (mean 54 +/- 10 years). In 37 (31%) patients AS symptoms manifested at the age under 55 years. Significant factors of early AS risk were age, hyperlipidemia, arterial hypertension, menopause for women, APL antibodies circulation, stage IV chronic disease of the kidneys, hyperuricemia, higher blood creatinine, mean dose of prednisolone over 15 mg/day, frequent elevation of the level of C-reactive protein. A direct correlation between lupus nephritis or nephrotic syndrome (NS) and early AS was not found. In LN hyperlipidemia occurred more often (p = 0.055), lipids level and NS were not related during its remission. LN patients developed AS more frequently, had lower complement concentration in the end of the study, were treated with prednisolone more intensively than patients free of renal disease (p < 0.05). CONCLUSION: Early AS develops in more than one third of SLE patients. Main risk factors of early AS are conventional ones and APL antibodies, persistence of chronic inflammation, decreased glomerular filtration rate, prednisolone therapy. LN influence on the process of atherogenesis in SLE may be mediated and caused by high rate of other risk factors.     

激素联合来氟米特治疗狼疮性肾炎疗效观察

目的了解来氟米特（LEF）治疗Ⅳ型狼疮性。肾炎的临床效果、安全性和副作用。方法59例狼疮性肾炎（LN）患者,肾活检显示为狼疮性肾炎,应用来氟米特联合糖皮质激素治疗6个月。用药期间监测血常规、尿常规、24h尿蛋白定量、肝肾功能、抗核抗体及抗双链抗体滴度、红细胞沉降率和补体c3等,6个月后行疗效和安全性的评价。结果来氟米特治疗LN尿蛋白缓解率为72．4％,高于环磷酰胺冲击治疗缓解率（57％）,LN活动性指标缓解率也高于后者。结论来氟米特联合糖皮质激素治疗能有效控制狼疮活动且副作用轻,耐受性好。     

Clinicomorphological features of nephropathy in primary and secondary antiphospholipid syndrome

AIM: To investigate specific features of extrarenal manifestations of antiphospholipid syndrome (APS) in patients with APS-associated nephropathy (APSN) in primary APS and lupus nephritis (LN) with secondary APS; to compare clinicomorphological signs of APSN in primary and secondary APS. MATERIAL AND METHODS: We examined 44 APSN patients with primary APS and 90 patients with LN: 57 with secondary APS, 33 with antiphospholipid antibodies (APA) without history of thrombosis. In addition to clinical and immunological examination, detection of serological APS markers, morphological examination of renal tissue and ultrasound dopplerography (USDG) of the renal vessels were made (in some patients) for assessment of the condition of intrarenal vascular bed. RESULTS: In patients with primary APS, renal disorder and secondary APS in LN frequency of arterial thrombosis doubles that of venous ones. Renal disorder irrespective of a clinical APS form (primary, secondary) combines with affection of the CNS, heart and skin (livedo). This correlates with frequency of arterial thrombosis. In patients with primary APSN rate of arterial hypertension (AH), especially severe, and renal dysfunction is higher than in LN with APS while this group is characterized by more severe proteinuria, microhematuria and higher incidence of nephrotic syndrome. A direct correlation exists between the incidence of arterial thrombosis and severity of AH, between AH and renal ischemia by USDG. Morphologically, glomerulosclerosis, marked arteriolosclerosis and diffuse interstitial sclerosis occur more often in patients with primary APSN compared to LN patients with APS. CONCLUSION: In primary and secondary (in SLE) APS combination of APSN with impairment of the CNS, heart and skin, correlation of its basic clinical manifestations with arterial thrombosis allow us to single out a special clinical variant of APS manifesting with generalized ischemic lesions of the organs as a result of arterial/arteriolar thrombosis. Irrespective of its nature, APSN has common characteristic features--combination of AH, persistent renal dysfunction and transitory hypercreatininemia--correlating with development of arterial thrombosis; therefore, this pathology can be considered as a variant of thrombotic vascular lesion of the kidneys.     

接触系统和中性粒细胞细胞外网络在狼疮性肾炎致病中的作用

目的：探讨接触系统与中性粒细胞细胞外网络(NETs)在狼疮性肾炎(LN)中的作用机制。方法 LN患者70例分为 LN 发作期组和 LN 缓解期组,另选择原发病为慢性肾小球肾炎的慢性肾脏病(CKD)患者8例作为CKD 组,正常健康查体人群22例作为健康对照组。分别检测血清中瓜氨酸化的组蛋白 H3(CitH3)和高分子量激肽原(HK)的浓度。结果①LN 发作期组血清 HK 水平明显低于其余3组;血清 CitH3水平明显高于其余3组(P <0.01)。②发作期血清 HK 水平明显低于缓解期,而血清 CitH3水平明显高于缓解期(P <0.05)。③LN 患者血清HK 水平与 CitH3水平呈负相关(r =-0.22,P <0.05)。结论接触系统和 NETs 共同参与了 LN 的进展。     

IL-12和IgG在狼疮肾炎患者中表达的意义

目的：探讨狼疮肾炎患者白细胞介素－12（IL－12）和免疫球蛋白（Ig）G水平表达的意义。方法：采用酶联免疫吸附法（ELISA）检测39例疮肾炎患者及11名正常人的外周血单个核细胞（PBMC）培养上清液中IL－12和IgG水平，并作比较。结果：狼疮肾炎活动期、静止期IL－12和IgG水平较正常对照均明显升高（P＜0.01），并且在活动狼疮肾炎IL－12与IgG水平呈正相关。结论：狼疮肾炎PBMC异常分泌IL－12、IgG，IL－12通过促进自身抗体分泌参与狼疮肾炎发病，IL－12水平可反映狼疮肾炎活动程度。     

MCP-1在狼疮性肾炎患者血浆及尿中的检测水平及意义

目的检测狼疮性肾炎(LN)患者治疗前后尿及血浆中单核细胞趋化蛋白-1(MCP-1)的表达水平及其临床意义,并进一步探讨MCP-1的水平与狼疮性肾炎进展的关系。方法实验分成4组:14例疾病活动期狼疮性肾炎患者(A组)、10例非疾病活动期狼疮性肾炎患者(B组)、16例无肾脏损害的系统性红斑狼疮患者(C组)及10例健康对照组(D组)。采用酶联免疫吸附法(ELISA法)检测LN患者尿及血浆中MCP-1的水平。结果 1狼疮性肾炎患者尿MCP-1水平显著高于正常对照组(P0.05)及无肾脏损害的系统红斑狼疮组(P0.05)。2尿MCP-1水平在狼疮性肾炎疾病活动期较非活动期增高(P0.05)。3治疗达缓解后的狼疮性肾炎患者尿MCP-1水平较治疗前明显降低(P0.05),血浆MCP-1水平在各组之间的差异无统计学意义。4尿MCP-1水平与尿蛋白定量、尿素氮、尿白蛋白、肌酐清除率呈正相关。血浆MCP-1只与尿蛋白定量呈正相关,其他指标均无相关性。结论尿MCP-1的水平可能与狼疮性肾炎的疾病进展相关,尿MCP-1可能成为狼疮性肾炎诊断及预后的生物学标志。     

系统性红斑狼疮与眼底改变关系的探讨

目的：探讨系统性红斑狼疮(SLE)与眼底改变的关系，为SLE的早期诊断、鉴别、治疗及预后提供依据。方法：对1994年1月至2002年12月在本院住院的423例SLE患者进行回顾性统计分析，了解影响SLE患者眼底改变的常见因素。结果：除性别外，眼底改变与视力、血压、系统性红斑狼疮疾病活动指数(SLEDAI)积分、血清肌酐(Scr)升高、C3下降、死亡率增加、是否狼疮性肾炎(LN)等均有密切的关系。结论：及时眼底检查可为SLE的早期诊断、鉴别、治疗及预后提供依据。     

Nephrotic syndrome and pregnancy. Potential problems for mother and child

The pregnant patient with nephrotic syndrome should be carefully evaluated for the presence of chronic renal disease. Proteinuria itself may be associated with an increase in perinatal mortality and in the incidence of small-for-gestational-age infants. Coexistent hypertension and/or renal dysfunction add to the risk of an unsuccessful pregnancy. The use of tocolytic agents in pregnant women with nephrotic syndrome theoretically may be hazardous. The patient with systemic lupus erythematosus may be at particular risk of unsuccessful pregnancy if the disease is active; postponement of conception until a remission of six months or longer has been achieved may be well advised.     

Pregnancy and medications for inflammatory bowel disease: An updated narrative review

Inflammatory bowel disease (IBD) is often diagnosed during the peak reproductive years of young women. Women with active IBD around conception are at a significantly increased risk of disease relapse during pregnancy, which is associated with poor pregnancy and neonatal outcomes. Given these substantial risks, it is prudent that disease remission should ideally be achieved before conception. Unfortunately, some patients may experience a disease flare-up even if they are in a state of remission before pregnancy. Patients must continue their IBD medications to reduce the risk of disease flare and subsequent poor outcomes during the gestational and postpartum periods. When treating IBD flare-ups during pregnancy, the management is quite similar to the therapeutic approach for non-pregnant patients with IBD, including 5-aminosalicylate, steroids, calcineurin inhibitors (CNIs), and biologic therapies. While the data regarding the safety of CNIs in pregnant women with IBD is limited, the findings in our recent meta-analysis suggest that CNIs may be safer to use in those with IBD than in solid organ transplant recipients. There are several types of biologics and small-molecule therapies currently approved for IBD, and physicians should thoroughly understand their clinical benefits and safety profiles when utilizing these treatments in the context of pregnancy. This review highlights recent studies, including our systematic review and meta-analysis, and discusses the clinical advantages and safety considerations of biologics and small molecules for pregnant women with IBD.     

抗心磷脂抗体在狼疮肾炎患者中的临床意义

背景:以往的研究表明,在系统性红斑狼疮及抗磷脂抗体综合征患者中,升高的抗心磷脂抗体滴度与血管血栓形成、血小板减少及反复流产的发生明显相关.但有关抗心磷脂在狼疮性肾炎患者中的临床意义的研究报道却不完全统一.目的:探讨抗心磷脂抗体在中国狼疮性肾炎患者中的阳性率及临床意义.设计:前瞻性单一样本的随访观察.单位:深圳市第四人民医院香蜜湖风湿病分院,广东医学院深圳风湿病研究所.对象:选择2001-03/2003-10于深圳市第四医院香蜜湖风湿病分院风湿科门诊就诊或住院的狼疮性肾炎患者97例.均符合美国风湿病学学会(ACR).1997年修订的狼疮性肾炎的诊断和分类标准.纳入对象均对检测项目知情同意.方法:记录患者入院后的临床资料和辅助检查结果.应用酶联免疫吸收法检测患者血清中的抗心磷脂抗体,阳性判断标准为测定值超过100 U/mL.大剂量口服强的松联合环磷酰胺静脉冲击治疗以诱导缓解,然后逐渐将强的松减量,将环磷酰胺换成硫唑嘌呤以维持疗效.同时使用其它药物控制可能合并的高血压、高血脂与关节痛等症状.每半年对纳入对象进行定期随访,记录狼疮性肾炎患者的临床资料及实验室检查结果,共3年.主要观察指标:患者的性别、年龄、系统性红斑狼疮病情活动指数,血栓形成、病理妊娠等临床表现及肾功能等实验室检查结果.结果:实验共纳入狼疮性肾炎患者97例,83例进入结果分析,14例脱落.在入选的97例患者中,其发病后被确诊时抗心磷脂抗体阳性者有38例(39%),高血压,血小板减少及雷诺现象在伴有抗心磷脂抗体阳性的狼疮性肾炎患者中更为常见.IgG型抗心磷脂抗体阳性狼疮件肾炎患者更易发生血管血栓形成:抗心磷脂抗体阳性狼疮性.肾炎患者更易发生流产、早产和死胎以及慢性肾功能不全恶化.结论:抗心磷脂抗体在狼疮性肾炎患者中的阳性率为39%,抗心磷脂抗体阳性的患者更易出现高血压,血小板减少及雷诺现象,抗心磷脂抗体阳件对预测狼疮性肾炎出现血管血栓形成、病理妊娠及慢性肾功能不全恶化可能有一定作用.     

Diabetes mellitus: impact on pregnancy

Diabetes Mellitus as a predisposing condition in pregnancy places the mother and fetus at increased risk for complications. Nevertheless, a successful pregnancy with a healthy baby is a realistic goal for most diabetic women today. The emphasis is on maintaining good control of blood glucose levels before conception and during pregnancy to minimize the risks. This article explains the physiology of diabetes and pregnancy and the metabolic changes that occur. It outlines the plan of management during pregnancy and the postpartum period and presents a review of the major complications that could affect the infant of the diabetic mother. A multidisciplinary team approach is also stressed as a positive influence affecting the outcome of a diabetic pregnancy.     

导乐陪伴分娩的临床研究

目的 探讨导乐陪伴分娩对妊娠结局的影响。方法 选择自愿要求导乐陪伴分娩的产妇318例(导乐组)与同期无人陪伴的初产妇215例(对照组),观察比较两组分娩方式、产程时间、产后出血及新生儿Apgar评分。结果 导乐组产妇的难产发生率(10.38％)和新生儿窒息(2.52％)明显低于对照组(28.37％,11.16％);前者的总产程时间为(6.14±2.74)h,产后出血量为(249.06±58.77)ml,均明显低于后者。结论 导乐陪伴分娩能降低难产率和新生儿窒息,缩短产程时间,减少产后出血,对母婴更加安全。     

狼疮肾炎外周血单个核细胞LFA—1表达

目的检测淋巴细胞功能相关抗原-1(LFA-1)在狼疮肾炎外周血单个核细胞中的表达并对其临床价值进行探讨.方法通过分离外周血单个核细胞,利用流式细胞术检测了狼疮肾炎外周血单个核细胞LFA-1表达.结果狼疮肾炎活动组外周血单个核细胞LFA-1表达高于非活动组和健康对照组(7.49±1.17vs2.67±0.65、2.21±0.32,P值均小于0.01),而非活动组与健康对照组则无明显差异(P＞0.05).LFA-1表达与狼疮活动指数呈正相关(r=0.746,P＜0.01).与狼疮活动指标抗核抗体、抗双链DNA抗体呈正相关(r值分别为0.627、0.705,P＜0.01),与补体(C3)呈负相关(r=-0.538,P＜0.01).结论LFA-1分子与狼疮活动密切相关,临床上可以作为狼疮活动的参考指标.     

Perceived health six months after delivery in women who have experienced low back pain and pelvic pain during pregnancy

BACKGROUND AND OBJECTIVES: A majority of women suffer from low back pain and pelvic pain (LBPP) during pregnancy. The aim of the study was to investigate perceived health, sexual life, social situation, sick leave and use of medical services 6 months after pregnancy in women with LBPP during pregnancy. RESEARCH METHODS: In a previous questionnaire study, 72% (n = 639) of the respondents had reported LBPP during pregnancy. These respondents were sent a second questionnaire approximately 6 months after delivery. The respondents were divided into three groups: 'no pain', 'recurrent pain' and 'continuous pain'. Pearson's chi-squared test was used to test the difference between groups. RESULTS: Perceived health status 6 months after pregnancy was less favourable for women with persistent LBPP compared to women with remission of LBPP. Family situation, change of relationship and sexual life did not differ among women with remission of LBPP or persistent LBPP after pregnancy. Four of 10 women with persistent LBPP had sought medical care, and two of 10 had been on sick leave because of LBPP after pregnancy. CONCLUSIONS: Perceived health status was less favourable for women with persistent LBPP after pregnancy. Use of medical services among women with persistent LBPP was prevalent.     

Acute pancreatitis in the postpartum period: a population-based case-control study

OBJECTIVE: To determine relationships among pregnancy (during and postpartum), acute pancreatitis, and gallstones. PATIENTS AND METHODS: In this retrospective population-based case-control study, we identified all 12- to 50-year-old Rochester, Minn, females diagnosed between 1976 and 1991 as having acute pancreatitis (cases). For each case, we matched 4 women of the same age (+/- 6 years) with no history of acute pancreatitis (controls). Acute pancreatitis was defined as associated with pregnancy if it occurred from 10 months prior to delivery to delivery and with the postpartum period if it occurred within 10 months of the date of delivery. Logistic regression was used to assess associations between pregnancy-related acute pancreatitis, age, gallstone occurrence, and alcohol use. RESULTS: In a cohort of 61 women who developed acute pancreatitis and 244 controls, the relative risk for acute pancreatitis associated with pregnancy was 1.43 (95% confidence interval, 0.61-3.40). All 10 cases of acute pancreatitis associated with pregnancy occurred in the postpartum period. Gallstones were present in 6 of them compared with 13 of 51 women with non-pregnancy-related acute pancreatitis (P < .05). Women with postpartum-related pancreatitis were younger than those with non-pregnancy-related pancreatitis (mean, 28 vs 36 years; P < .05). Alcohol was not associated with pregnancy-related pancreatitis. CONCLUSIONS: Acute pancreatitis during the postpartum period is not directly related to pregnancy but is associated with gallstones and occurs in younger women.     

Platelet dysfunction and pregnancy in gestational exacerbation of chronic glomerulonephritis]

AIM: To evaluate platelet dysfunctions and pregnancy outcomes in females with gestational exacerbation of chronic glomerulonephritis (CGN) and the disease remission. MATERIALS AND METHODS: Platelet metabolism was studied by activity of intraplatelet LDG, platelet secretory activity by plasm beta-TG and ADP-aggregation in 75 gravidae. Of them 16 had exacerbation of CGN, 40 females were in remission of CGN and 19 healthy pregnant women served control. RESULTS: Enhanced LDG activity and intensity of maximal ADP aggregation, high beta-TG levels compared to control were recorded in gravidae with CGN both in exacerbation and remission. The frequency of preterm deliveries, intrauterine growth retardation, neonatal hypotrophy was greater in women with gestational exacerbation of nephritis compared to pregnant women with stable nephritis. CONCLUSION: Metabolic and functional platelet hyperactivity with platelet intravascular activation in pregnancy in aggravated CGN suggest contribution of platelets to onset of the disease gestational exacerbation. Pregnancy-induced overactivation of platelets in CGN exacerbation stimulates intravascular coagulation in placental circulation with resultant microthrombi in placental vessels responsible for high rate of unfavorable pregnancy outcomes in relevant patients.