Lupus nephritis flare versus superimposed preeclampsia — emergency management station

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

Prompt

A 32-year-old G2P1 at 26 weeks with known class IV lupus nephritis (baseline creatinine 90 micromol/L on tacrolimus, hydroxychloroquine and azathioprine) presents with a 3-day history of swelling, headache and reduced urine output. Her blood pressure is 158/100 mmHg, her creatinine has risen to 135 micromol/L, her PCR has risen from 50 to 200 mg/mmol, and her complement C3 has fallen from 0.85 to 0.48 g/L with a rising dsDNA titre. Her PlGF is normal at 180 pg/mL. She is anti-Ro/La positive and her aPL panel is being rechecked. You are the registrar; the consultant is 15 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.^[3]

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.^[6]^[12]

References5Show

[2]Tektonidou MG, Andreoli L, Limper M, Amoura Z, Cervera R, Costedoat-Chalumeau N, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults Ann Rheum Dis, 2019.PMID 31092409
[3]Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases Arthritis Rheumatol, 2020.PMID 32090480
[6]Kim MY, Buyon JP, Guerra MM, Rana S, Zhang D, Laskin CA, Petri M, Lockshin MD, Sammaritano LR, Branch DW, Porter TF, Merrill JT, Stephenson MD, Gao Q, Karumanchi SA, Salmon JE Angiogenic factor imbalance early in pregnancy predicts adverse outcomes in patients with lupus and antiphospholipid antibodies: results of the PROMISSE study Am J Obstet Gynecol, 2016.PMID 26432463
[8]Izmirly PM, Costedoat-Chalumeau N, Pisoni CN, Khamashta MA, Kim MY, Saxena A, Friedman D, Llanos C, Piette JC, Buyon JP Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro-antibody-associated cardiac manifestations of neonatal lupus Circulation, 2012.PMID 22626746
[12]Hladunewich MA, Bramham K, Jim B, et al. Managing glomerular disease in pregnancy Nephrol Dial Transplant, 2017.PMID 28391337

Lupus nephritis flare versus superimposed preeclampsia — emergency management station

Station brief

References5Show

[2]Tektonidou MG, Andreoli L, Limper M, Amoura Z, Cervera R, Costedoat-Chalumeau N, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults Ann Rheum Dis, 2019.PMID 31092409
[3]Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases Arthritis Rheumatol, 2020.PMID 32090480
[6]Kim MY, Buyon JP, Guerra MM, Rana S, Zhang D, Laskin CA, Petri M, Lockshin MD, Sammaritano LR, Branch DW, Porter TF, Merrill JT, Stephenson MD, Gao Q, Karumanchi SA, Salmon JE Angiogenic factor imbalance early in pregnancy predicts adverse outcomes in patients with lupus and antiphospholipid antibodies: results of the PROMISSE study Am J Obstet Gynecol, 2016.PMID 26432463
[8]Izmirly PM, Costedoat-Chalumeau N, Pisoni CN, Khamashta MA, Kim MY, Saxena A, Friedman D, Llanos C, Piette JC, Buyon JP Maternal use of hydroxychloroquine is associated with a reduced risk of recurrent anti-SSA/Ro-antibody-associated cardiac manifestations of neonatal lupus Circulation, 2012.PMID 22626746
[12]Hladunewich MA, Bramham K, Jim B, et al. Managing glomerular disease in pregnancy Nephrol Dial Transplant, 2017.PMID 28391337