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lupus patient. These include the serum sodium, potassium, calcium and phosphate levels, as
well as the hemoglobin [66-71].
A kidney ultrasound may also be performed, to confirm that two kidneys are present and
to document their size. Sometimes other tests may be undertaken such as an radiologic
isotope renogram, which can measure the extent that each kidney contributes to overall renal
function [66-71]. If clinically indicated, the precise degree of disease activity may be
ascertained via a kidney biopsy. Renal biopsy is now a routine procedure in hospitals
throughout the world. For best results, it is often conducted with ultrasound guidance.
Following local anesthesia, a needle is inserted into the kidney and a small core biopsy is
obtained. The patient is usually kept in the hospital overnight, as there is a small risk of
bleeding following the biopsy. The procedure has a high safety margin, and does not
adversely affect kidney function.
Classically, the first pathologic signs of lupus renal involvement involve
lymphohistiocytic infiltrates surrounding the glomeruli. A more advanced histologic stage is
direct inflammation and damage within the glomeruli. Severe histologic stages involve
extensive involvement and scarring of the glomeruli [66-71]. There are international
conventions about staging the damage within the kidney biopsy; pathologists are thus able to
determine the chances of response to treatment from their reading of the biopsy. Current
clinical consensus mandates that if histologic kidney inflammation exists, a therapeutic
regimen of 1) steroids and 2) an additional immunosuppressive agent is warranted [66-71].
For active or severe lupus renal disease, the most widely used additional immunosuppressive
is cyclophosphamide (given intermittently by injection). In the past, cyclophosphamide was
given as a tablet; however, this route of administration produced more side effects and most
clinics have now converted to intermittent injection pulses [72].
Doses vary from clinic to clinic; however, a recent trend has been to utilize lower doses,
with the benefit of fewer side effects. A second, milder and widely used lupus
immunosuppressive is azathioprine, given as tablet and usually at a dose of about 2mg/kg
body weight. A third tablet immunosuppressive that is becoming more widely used is
mycophenolate mofetil [72].
Studies are underway to see if it might supersede cyclophosphamide, which would be
advantageous as it does not cause as many serious side effects. It would further be useful if a
patient does not tolerate azathioprine. All immunosuppressives can affect the blood cell
count; thus, regular complete blood counts are mandatory for patients taking these
medications. Other immunosuppressive drugs such as cyclosporine A are increasingly utilized
in lupus therapy, but the current primary mainstays of treatment remain cyclophosphamide
and azathioprine [73].
Finally, if the kidney damage reaches a stage where toxic blood metabolites are
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increasing, then dialysis is vital. Dialysis is one of the major advances in twentieth century
medicine; either haemodialysis or peritoneal dialyses have assisted thousands of patients with
lupus renal failure [74].
One of the surprises in the early days of lupus renal transplantation was the finding that
lupus consistently did not damage the transplanted kidney [75]. The reasons for the finding
are not known; however, the finding could be related to the strong immunosuppression
utilized with transplantation, and possibly to other factors. Patients with lupus who undergo
renal transplantation have largely successful clinical outcomes [75].

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