Annals for Educators - 19 February 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives19 February 2019Annals for Educators - 19 February 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201902190 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsRenal Transplantation and Survival Among Patients With Lupus Nephritis. A Cohort StudyRenal transplantation is associated with increased survival among patients with end-stage renal disease (ESRD). However, the benefits of renal transplant in patients whose ESRD is due to lupus nephritis (LN-ESRD) is uncertain. This analysis compared survival among patients with LN-ESRD who did and did not have a kidney transplant.Use this study to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners what the potential benefits and risks of renal transplant are among patients with ESRD.What are potential reasons for renal dysfunction among patients with systemic lupus erythematosus?Why might patients with LN-ESRD have a worse prognosis after renal transplant than those whose ESRD is due to another cause?The authors and the editorialists note the potential for confounding by indication (or contraindication) and immortal time bias in their study. What are these types of bias? Why is it important to look for potential sources of bias in a study? Antiphospholipid Antibodies in Patients With Myocardial InfarctionAntiphospholipid syndrome (APS) is defined by arterial, venous, or microvascular thrombosis or obstetric morbidity together with confirmed antiphospholipid antibodies (aPLs). This large study assessed the frequency of aPLs among patients with a first myocardial infarction.Use this paper to:Ask your learners what the potential presentations of APS are. Use the information in DynaMed Plus: Antiphospholipid antibody syndrome, a benefit of your ACP membership, to help prepare. How is the diagnosis made?How should patients with APS be managed? What may be used (and what may not be used) to help prevent recurrent pregnancy loss?Review the results of this brief research report. What further studies should be done to determine whether we should test patients with a first myocardial infarction for aPLs?Annals for Hospitalists Inpatient Notes - Clinical Pearls—Acute PancreatitisAcute pancreatitis is a common reason for hospitalization. This month's Annals for Hospitalists Inpatient Notes provides a concise presentation and discussion of a woman with acute pancreatitis complicated by infected pancreatic necrosis. Are your learners prepared to recognize and manage this complication?Use this feature to:Read the brief case presentation to your learners. Ask how they would manage the patient's care upon initial presentation.Ask how your learners approach fluid management in pancreatitis. What about nutrition? Do they agree that early enteral nutrition is best for most patients? Review the information in the recently featured Beyond the Guidelines, “ How Would You Treat This Patient With Gallstone Pancreatitis?” and the recent Annals for Educators for ideas on how to use this feature to teach. How is infected pancreatic necrosis recognized? How is it treated? What are the risks?Video LearningAnnals Consult Guys - Surgery With Aortic Stenosis?In this episode of the consultative medicine talk show, Drs. Merli and Weitz tackle the difficult question of whether to alter surgical plans on account of aortic stenosis.Use this feature to:Take a break with your learners to watch the short, fun, and educational video.Pause the video after the viewer's letter is read to ask your learners how they would approach the question.Use the short multiple-choice questions to assess your learners' knowledge. Log on and enter your answers to earn CME and MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Being RelevantDr. Zitter describes her role as a physician on the team, even when there are no “medical” decisions to make.Use this essay to:Listen to an audio recording, read by Annals Associate Editor for On Being a Doctor, Dr. Michael LaCombe. How can we still be important to our patients when we cannot provide a cure?Do your learners feel threatened or uncomfortable when a nonphysician member of the care team is “in charge”? Why might physicians find this threatening?On Being a Doctor: BunDr. Weinberg recalls the gift from a little girl who sensed that he could provide her shelter.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Have your learners bonded with a patient who has died? How? What circumstance created such a bond that might not have been present with another patient who died?How does this bond differ from those created with patients for whom we are able to provide medical remedies for their ailments?Annals Graphic MedicineAnnals Graphic Medicine - Progress Notes: CancerDr. Natter graphically tells the story of the encounter in which seeing himself in his patient stopped him in his tracks.Use this feature to:Share the cartoon with your learners.Have they had similar experiences? Why does the experience of some patients hit us so hard?Are there reactions that might be problematic and that might compromise our care for our patients? How can we use these reactions to make us better physicians?MKSAP 18 Question 1A 32-year-old woman is evaluated for an 8-week history of fatigue and low-grade fever. She also reports swelling and tenderness of the hand joints, along with morning stiffness lasting 2 hours. Over the past 2 weeks, she has been taking naproxen with relief. Last week, she developed swelling of the legs and gained 4.5 kg (10 lb).On physical examination, blood pressure is 152/96 mm Hg; other vital signs are normal. A malar rash is present. Active tenderness and swelling of multiple joints of the hands are noted. There is pitting edema of the lower extremities. The remainder of the physical examination is normal.Laboratory studies:Erythrocyte sedimentation rate88 mm/hHematocrit38%Complements (C3, C4)LowCreatinine1.1 mg/dL (97.2 µmol/L)Antinuclear antibodiesTiter: 1:320Anti-Smith antibodiesPositiveAnti–double-stranded DNA antibodiesPositiveUrinalysis3+ protein; no erythrocytes; no leukocytes; no castsUrine protein4000 mg/24 hWhich of the following tests is most appropriate to perform next to assess this patient's kidney disease?A. Antiphospholipid antibodiesB. CT of the abdomen and pelvisC. Kidney biopsyD. Renal arteriographyE. Serum and urine protein electrophoresisCorrect AnswerC. Kidney biopsyEducational ObjectiveEvaluate kidney disease in systemic lupus erythematosus.CritiqueKidney biopsy should be performed to assess this patient's kidney disease. Lupus nephritis occurs in up to 70% of patients with systemic lupus erythematosus (SLE); the presence of anti–double-stranded DNA antibodies is a marker for risk. This patient's symptoms and laboratory findings, including constitutional symptoms, inflammatory polyarthritis, a malar (butterfly) rash, positive autoantibodies (antinuclear, anti-Smith, and anti–double-stranded DNA antibodies), hypocomplementemia, and proteinuria, are suggestive of SLE. She likely has the nephrotic syndrome due to lupus nephritis, and further evaluation is needed. Kidney disease is frequent in SLE and can be seen in 10% to 30% of patients at initial presentation. There are six different pathologic classes of kidney involvement in SLE with significant prognostic and therapeutic implications. Kidney biopsy is the diagnostic test of choice to assess and categorize the kidney disease and should be performed in most cases. Indications for kidney biopsy are as follows: increasing serum creatinine without explanation, proteinuria >1000 mg/24 h, proteinuria >500 mg/24 h with hematuria, and proteinuria >500 mg/24 h with cellular casts.Testing for antiphospholipid antibodies is appropriate to complete this patient's evaluation but will not help to further assess her kidney disease.CT of the abdomen and pelvis may reveal masses or retroperitoneal obstruction but is unlikely to be helpful in diagnosing the cause of the nephrotic syndrome. Renal vein thrombosis can present with proteinuria but cannot account for this patient's rash, polyarthritis, or hypocomplementemia.Renal arteriography should be performed in patients with medium-vessel vasculitis such as polyarteritis nodosa. This patient has SLE, and the vasculitis in SLE is small-vessel immune complex–mediated, in which arteriogram is usually normal and would unnecessarily expose the patient to nephrotoxic dye.Serum and urine protein electrophoresis can assess a myeloproliferative disorder, which is not suspected in this patient with rash, polyarthritis, and the nephrotic syndrome.This content was last updated in August 2018.Key PointKidney biopsy is the diagnostic test of choice to assess and categorize kidney disease in patients with systemic lupus erythematosus and is usually essential to make therapeutic decisions.BibliographyAlmaani S, Meara A, Rovin BH. Update on lupus nephritis. Clin J Am Soc Nephrol. 2016.MKSAP 18 Question 2A 21-year-old woman is evaluated during a follow-up visit for a 1-year history of systemic lupus erythematosus. At the time of diagnosis, she presented with a malar rash and arthritis, along with positive antinuclear and anti–double-stranded DNA antibodies. Medications are hydroxychloroquine, low-dose prednisone, calcium, and vitamin D. She currently feels well and is asymptomatic.Vital signs are normal, and the physical examination is unremarkable.Laboratory studies:C340 mg/dL (400 mg/L)C48 mg/dL (80 mg/L)Anti–double-stranded DNA antibodiesPositive (titer: 1:320)Urinalysis2+ blood; 2+ protein; dysmorphic erythrocytes; no castsUrine protein-creatinine ratio600 mg/gKidney ultrasound shows kidneys of normal size and echogenicity.Which of the following is the most appropriate next step in management?A. Begin pulse glucocorticoids followed by cyclophosphamideB. Begin pulse glucocorticoids followed by mycophenolate mofetilC. Increase oral prednisone dose and add mycophenolate mofetilD. Schedule a kidney biopsyCorrect AnswerD. Schedule a kidney biopsyEducational ObjectiveDiagnose lupus nephritis.CritiqueThe most appropriate next step is a kidney biopsy. The presence of hematuria, dysmorphic erythrocytes, and proteinuria in a patient with known systemic lupus erythematosus (SLE) is highly suggestive of lupus nephritis; when serologies are positive and serum complement levels are low, this diagnosis is even more likely. Commonly cited indications for kidney biopsy include increasing serum creatinine without explanation, proteinuria >500 mg/24 h, or active urine sediment (dysmorphic erythrocytes, erythrocyte casts). Patients meeting these criteria are more likely to have focal or diffuse proliferative lupus nephritis or lupus membranous nephropathy requiring immunosuppressive therapy. Patients with proteinuria <500 mg/24 h and inactive urine sediment are more likely to have milder kidney involvement and may be followed with urinalysis, urine protein-creatinine ratio, and serum creatinine every 3 to 6 months.Unless absolutely contraindicated (for example, bleeding diathesis or inability to stop anticoagulation), both rheumatology and nephrology guidelines support performing a kidney biopsy in patients with SLE who develop evidence of significant kidney involvement to establish the diagnosis and, of equal importance with regard to treatment decisions, to identify the International Society of Nephrology/Renal Pathology Society (ISN/RPS) class of lupus nephritis.This patient's kidney biopsy could show a proliferative lupus nephritis (class III or IV), in which case treatment with glucocorticoids and mycophenolate mofetil or cyclophosphamide would be indicated (mycophenolate mofetil would likely be preferred given this patient's age). However, her biopsy could also conceivably show a milder, mesangial proliferative lupus nephritis (class II) or membranous lupus nephritis (class V), neither of which would require immunosuppression at this stage. Therefore, empiric therapy in this setting is substandard to biopsy-guided therapy according to ISN/RPS class of nephritis.Key PointA kidney biopsy should be performed in patients with known systemic lupus erythematosus with suspected significant kidney involvement to establish the diagnosis and to identify the class, which will guide treatment decisions.BibliographyHahn BH, McMahon MA, Wilkinson A, Wallace WD, Daikh DI, Fitzgerald JD, et al; American College of Rheumatology. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken). 2012;64:797-808.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 19 February 2019Volume 170, Issue 4Page: ED4KeywordsAntibodiesBiopsyKidneysLupus erythematosusLupus nephritisProteinuriaRenal diseasesRenal failureRenal transplantationUrine ePublished: 19 February 2019 Issue Published: 19 February 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...