Lupus nephritis (LN) is an inflammatory condition of the kidneys that encompasses various patterns of renal disease including glomerular and tubulointerstitial pathology. It is a major predictor of poor prognosis in patients with systemic lupus erythematosus (SLE). Genetic factors, including several predisposing loci, and environmental factors, such as EBV and ultraviolet light, have been implicated in the pathogenesis. It carries a high morbidity and mortality if left untreated. Renal biopsy findings are utilized to guide treatment. Optimizing risk factors such as proteinuria and hypertension with renin-angiotensin receptor blockade is crucial. Immunosuppressive therapy is recommended for patients with focal or diffuse proliferative lupus nephritis (Class III or IV) disease, and certain patients with membranous LN (Class V) disease. Over the past decade, immunosuppressive therapies have significantly improved long-term outcomes, but the optimal therapy for LN remains to be elucidated. Cyclophosphamide-based regimens, given concomitantly with corticosteroids, have improved survival significantly. Even though many patients achieve remission, the risk of relapse remains considerably high. Other treatments include hydroxychloroquine, mycofenolate mofetil, and biologic therapies such as Belimumab, Rituximab, and Abatacept. In this paper, we provide a review of LN, including pathogenesis, classification, and clinical manifestations. We will focus, though, on discussion of the established as well as emerging therapies for patients with proliferative and membranous lupus nephritis.
Emphysematous Pyelonephritis (EPN) is a rare, gas-forming infection of the renal parenchyma associated with significant morbidity and mortality. We report the case of a 39 year-old woman with uncontrolled diabetes who presented with abdominal pain, fevers and chills for one month. Physical exam was notable for dry oral mucosa and left costovertebral angle tenderness. Labs showed acute kidney injury and a hyperglycemic hyperosmotic state. CT abdomen revealed emphysematous pyelonephritis with a large left renal abscess. EPN should be considered in diabetic patients, especially those with uncontrolled or new-onset diabetes and those presenting with symptoms of urinary tract obstruction. Prognostic factors include thrombocytopenia, shock, altered mental status and need for hemodialysis. Our patient was treated successfully with intravenous antibiotics, percutaneous drainage, strict glucose control and monitored with serial imaging. She underwent laparoscopic nephrectomy one month later. Early diagnosis of EPN is essential as it carries a high mortality and a strong clinical suspicion is required, as patients may have an atypical presentation.
Abdominal pain is a common symptom during pregnancy, but bowel obstruction as the cause is a rare phenomenon. Moreover, intestinal volvulus is an even more unusual cause of obstruction during pregnancy and normally involves the sigmoid colon. We report a unique case of midgut volvulus in a pregnant patient entering her third trimester who presented to the hospital with abdominal pain. Our case demonstrates the safety of computed topography in pregnancy while restricting radiation dose and highlights the need to have a high index of suspicion for bowel obstruction when approaching a pregnant patient with abdominal pain.
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