Lupus nephritis flare in pregnancy — emergency management station

Emergency station: lupus nephritis flare superimposed on CKD in pregnancy. Tests distinction of flare from superimposed preeclampsia, escalation of immunosuppression, blood pressure control, fetal surveillance and structured handover. Includes assessor key and marking domains.

Prompt

A 30-year-old G1P0 at 24 weeks with known lupus nephritis (CKD Stage 2, baseline creatinine 90 micromol/L on tacrolimus, hydroxychloroquine and azathioprine) presents with rising creatinine to 140 micromol/L, PCR rising from 50 to 180 mg/mmol, swelling and a malar rash. She has had two days of fever and joint pain. Her blood pressure is 150/96 mmHg, and her complement C3 has fallen from 0.9 to 0.5 g/L with a rising dsDNA titre. You are the registrar; the consultant is 20 minutes away.

Station brief

Format. Emergency management station, approximately 12 minutes. You are the obstetric registrar on the antenatal ward. A midwife, the renal fellow (on the phone) and the anaesthetist (10 minutes away) are with you; the obstetric consultant and rheumatologist are coming. The assessor feeds you new observations.^[1]

Candidate instruction. Lead the assessment and immediate management of a lupus nephritis flare in pregnancy. Verbalise your differential, your drug orders with doses, and your escalation triggers. Distinguish flare from superimposed preeclampsia explicitly.^[12]^[13]

References4Show

[1]Williams D, Davison J Chronic kidney disease in pregnancy BMJ, 2008.PMID 18219043
[3]Wiles K, Webster P, Seed PT, et al. The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes Nephrol Dial Transplant, 2021.PMID 33313680
[12]Webster P, Wardle A, Bramham K, et al. Tacrolimus is an effective treatment for lupus nephritis in pregnancy Lupus, 2014.PMID 24928830
[13]Hladunewich MA, Bramham K, Jim B, et al. Managing glomerular disease in pregnancy Nephrol Dial Transplant, 2017.PMID 28391337

Lupus nephritis flare in pregnancy — emergency management station

Station brief

References4Show

[1]Williams D, Davison J Chronic kidney disease in pregnancy BMJ, 2008.PMID 18219043
[3]Wiles K, Webster P, Seed PT, et al. The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes Nephrol Dial Transplant, 2021.PMID 33313680
[12]Webster P, Wardle A, Bramham K, et al. Tacrolimus is an effective treatment for lupus nephritis in pregnancy Lupus, 2014.PMID 24928830
[13]Hladunewich MA, Bramham K, Jim B, et al. Managing glomerular disease in pregnancy Nephrol Dial Transplant, 2017.PMID 28391337