Systemic lupus erythematosus (SLE) is a multisystem organ, with a variety of autoantibodies in autoimmune diseases. In women, male to female ratio was 1:7 ~ 9, the peak age of onset ranged from 15 to 35 years old. The renal damage is one of the main clinical manifestation of systemic lupus erythematosus, called lupus nephritis (LN), the incidence of a report. According to the domestic most doctors experience in diagnosis of systemic lupus erythematosus, approximately 70% had significant renal damage in systemic lupus erythematosus. If renal biopsy, with light microscope, the renal damage of 90%. with immunofluorescence and electron microscopy check, almost all have glomerular damage. Some patients can be extra renal manifestations, but only mild renal damage. The patients of kidney failure are few. Some patients with renal damage as the main performance, for example, can be manifested as nephrotic syndrome, and renal manifestations of unknown Obviously, easily misdiagnosed as primary glomerular disease.
A, clinical characteristics
Most of the 1. systemic manifestations of lupus nephritis patients (more than 80%) were in systemic lesions of systemic lupus erythematosus in 1 ~ 3 years. A minority of patients with renal involvement as the first clinical manifestation of lupus, even blood test were also negative. Inpidual patients with lupus nephritis after 15 years systemic involvement. Lupus nephritis systemic manifestations of fever, arthritis and skin lesions are the most common. With the involvement of the system of the liver, heart, central nervous system and hematopoietic organs, polyserositis. Has been observed in systemic lupus erythematosus and renal involvement, often accompanied by hair loss, oral ulcer the incidence of arthritis, but no renal involvement is relatively low.
2. urine test urine composition changes are important laboratory evidence of lupus nephritis and its variety, from simple proteinuria to severe proteinuria with obvious changes such as nephritis urine, hematuria, urine white blood cells, red blood cells cylindruria.
About 80% of 3. patients with moderate anemia hemogram (normocytic normochromic anemia, even with hemolytic anemia), thrombocytopenia, about 1/4 patients with pancytopenia.
4. more than 90% patients with ESR ESR were significantly faster.
5. plasma protein changes of plasma albumin decreased, may be related to urinary protein loss and liver synthesis decreased. Globulin electrophoresis showed significantly increased, gamma globulin increased significantly. Some patients with rheumatoid factor positive; or a mixture of multiple strains of IgG/IgM cryoglobulinemia are immunoglobulin expression.
There are 6. kinds of autoantibodies in the serum immunological examination, in untreated patients with active LN, visible: positive antinuclear antibody, the sensitivity is greater than 90%, the specificity was 70%, screening test for good. The anti double stranded DNA antibody (ds-DNA antibody) positive, the specificity of up to 96%, but the positive rate in the treatment of only 70% active SLE patients, is of great value for the disease activity of judgment. The positive rate of the anti -Sm antibody was about 42%, but the specificity is strong. Anti -Sm antibodies and disease activity, usually associated with a high incidence of visceral lesions and serious skin damage. Anti -Sm is antibody labelled antibodies, and disappear with the treatment, can be used as a retrospective diagnostic index.
7. lupus cells lupus cells of most patients were positive.
Total complement and complement C3 8., serum Clq, C4, C2 were significantly decreased, showing hypocomplementaemia.
Fibrin degradation product 9. fibrin degradation products in blood and urine increased.
The diagnosis of systemic lupus erythematosus in the general use of the American College of Rheumatology (ARA) diagnostic criteria revised in 1982, which is in line with the following 11 items in 4 or 4 or more can be diagnosed as systemic lupus erythematosus: zygomaticofacial butterfly erythema; the discoid; the light sensitive; the oral ulcer (often painless); the polyarthritis (joint swelling and pain); the serositis, pleurisy and pericarditis; and (or) renal damage (proteinuria or >50mg/d cells; tube type): the nervous system damage (epilepsy or mental illness); 9 blood system (hemolytic anemia or abnormal leukopenia or lymphopenia and thrombocytopenia); the immunological abnormalities, LE cells, anti ds-DNA antibody, anti Sm antibody positive or false positive syphilis serum test; the ANA positive standard. The sensitivity and specificity of 96%.
The diagnostic standard of our country academic conference in 1992 on rheumatism in systemic lupus erythematosus: Butterfly erythema or discoid; light sensitivity; the oral ulcer; the abnormal arthritis or joint pain; the serositis (pleurisy or pericarditis); the nephritis (proteinuria or hematuria or cylindruria) 7; nervous system damage (convulsions or mental symptoms); the blood abnormality (white cytoplasm "4X109/L or platelet <80 000/ml or hemolytic anemia); LE cells or anti d3-DNA antibody positive; the positive anti SM antibody; ANA positive; the positive lupus band test; @C3 complement more than 13 lower than normal. In line with the 4 can be confirmed. In the condition of the units, especially for some of the early atypical cases, with this standard, this standard sensitivity was 97.5%, specificity was 93.6%.
Have been diagnosed with systemic lupus erythematosus, such as abnormal urine, combined with hypertension, edema and other clinical laboratory evidence of renal damage and renal dysfunction, the diagnosis can be established lupus nephritis. Renal biopsy can identify the renal inflammation caused by pathological types and other reasons, can early diagnosis of renal manifestations lupus nephritis.
Three, western medicine treatment
1. general treatment
During the period of illness and treatment, should avoid factors induced SLE nephritis activity such as the sun, (penicillin, sulfa drugs, contraceptives), vaccination; pay attention to early treatment, early treatment, and actively, not only can achieve a better effect, and can improve the prognosis of this disease.
(1) the general selection of adrenocortical hormone prednisone. Initial treatment stage, adult 1mg/kg/d, morning meal, until 8 weeks after the start of the week reduction by 10%, until the small dose (day morning 1mg/kg) when the next day morning meal, according to the specific circumstances, consider the maintenance treatment for a period of time, gradually reduced to maintain the volume (day 0.4mg/kg), take for a long time. In severe cases, this year there are those who advocate for shock therapy, with methyl prednisone 1g/d, adding 5% glucose saline 250ml intravenous drip, 1 times a day, for 3 consecutive days, and then oral prednisone. The standard treatment can be repeated regularly using this shock therapy, and in the intermittent period of use a small dose of prednisone.
(2) azathioprine cytotoxic drugs. The drugs commonly used cyclophosphamide, and hormone combination, can reduce the amount of hormone, shorten the course of treatment, reduce the side effects of hormones; and the illness is heavy, single hormone invalid, combined with the use of this class of drugs can make the remission. Use of cyclophosphamide pulse therapy is recommended in recent years that is, in the above standard hormone therapy and treated with cyclophosphamide, namely the first stage cyclophosphamide for 8 ~ 12mg/kg, adding 100ml normal saline infusion, time not less than 1 hours, for 2 days, and to charge patients more water, more urination. After every 2 weeks after the impact of the 1, the cumulative total dose at 150mg/kg, every 3 months, the impact of time, for two days, until SLE nephritis by shock after treatment stabilized for 1 to 2 years, can consider to stop cyclophosphamide pulse therapy.
(3) plasma replacement therapy aims to remove plasma antigen, antibody, immune complexes and other abnormal proteins, eliminate inflammatory mediators, and improve the phagocytic function of reticuloendothelial system, so as to control the disease activity. Can be used for the combined treatment of shock treatment beyond the control of diffuse proliferative lupus nephritis activity, renal function a sharp deterioration.
(4) dialysis and renal transplantation for SLE nephritis caused by irreversible uremic patients.
Four, Chinese medicine treatment
(a) treatment based on syndrome differentiation
1. heat toxin syndrome
The clinical manifestations of fever or confused has fever, facial erythema, or a body rash, limb edema, joint pain, palpitations, even Shenhun delirium, or vomiting blood, nose bleeding, skin ecchymosis, constipation, dry mouth, red tongue, yellow greasy moss, thin slippery pulse number. Treated with Qingrejiedu, cool blood hemostatic method. In Xijiaodihuang Decoction (Buffalo, rehmannia, Radix Scrophulariae, paeonol, comfrey, radix paeoniae rubra, Oldenlandia, rhubarb, Artemisia annua). Water horn detoxification; Yin nourishing Yin is not the fire is not put out, so students, Scrophularia Qingreliangxue Yin, and help the water buffalo clear solution blood toxin; Radix Paeoniae rubra, paeonol, Lithospermum diffusa, cooling blood to stop bleeding; rhubarb, Artemisia Qingrejiedu. Hematuria, and rhizome size thistle, Huaihua; hair spot, and even Shenhun Qingdai; heat, with wood or Xuedan agnhw.
2. liver and kidney yin deficiency
The clinical manifestations of two dry, hot feeling, dry mouth and throat, hair tine shakes, Yaoxisuanruan or pain, dry stool, or long-term fever night sweats, red tongue without fur; or red urine, urine hot or hematuria; or dizziness and tinnitus, thready pulse. Treated by nourishing liver and kidney, nourishing yin and clearing heat method. In Qiju Dihuang Decoction (Chinese wolfberry, chrysanthemum, rehmannia, yam, Cornus, Anemarrhena, privet, honeysuckle, licorice). In Lycium rehmannia, Chinese yam, Cornus nourish liver and kidney; Hangzhou chrysanthemum Shufeng Qingre Mingmu; Rhizoma Anemarrhenae, Ligustrum lucidum, honeysuckle with licorice to reconcile various yangyinqingre; medicine. Urine heat, hematuria, and Imperata root, Verbena, Platycladus orientalis; dizziness and tinnitus, and silkworm, gastrodin.
3. spleen and kidney deficiency syndrome
The clinical manifestations of systemic edema, pale, Yaoxisuanruan weakness, heel pain, tinnitus, diarrhea, bloating, anorexia, limb cold, pale tongue, indented, dark matter, thready pulse treatment of tonifying spleen and kidney to temperature, regulating qi and activating blood. By Jisheng Shenqi Pill (born, rehmannia, Xianlingpi, tablets, dangshen, astragalus, polygonatum, Atractylodes, tuckahoe, yam, coix seed, Rhizoma alismatis, licorice). In Epimedium, dried rehmannia root, aconite tonifying kidney qi; dangshen, astragalus, polygonatum, Atractylodes, Poria yam, coix seed, Rhizoma alismatis Spleen Qi; Li water swelling; licorice to reconcile various drugs. Partial deficiency of Spleen Yang, Kako Yoshijiang, Cao nuts, costusroot; partial kidney yang, and Morinda, dodder, Achyranthes root.
4. Qi deficiency and blood stasis
The clinical manifestations of dizziness, lassitude, oropharyngeal dry, pale grey lag, subcutaneous petechiae, backache, hair loss, poor appetite, tongue reddish purpura, thin white fur, pulse fine. Treated by supplementing qi and nourishing Yin, promoting blood circulation and removing blood stasis. Shengmaisan Taohongsiwu Decoction (Radix Codonopsis, Radix Ophiopogonis, Schisandra chinensis, Ligustrum lucidum, astragalus, Cornus officinalis, Polygonum multiflorum, Dendrobium, angelica, salvia, chuanxiong, Herba Leonuri). In Radix Codonopsis, Radix Ophiopogonis, Schisandra chinensis, Ligustrum lucidum, Astragalus tonifying qi and Yin; Cornus officinalis, Polygonum multiflorum, Dendrobium, Radix Scrophulariae nourishing Yin Jin; Angelica, salvia, chuanxiong rhizome, motherwort Huoxue Huayu Tongluo. Phlegm turbid, additive pinellia, orange, bamboo shavings; edema, plantain seed, melon skin; damp heat, and baicalin, talc.
Five, life care
In patients with lupus nephritis should be adequate intake of nutrients, such as protein, vitamins, minerals, to light is appropriate. Moisture, salt should be appropriate restrictions. To avoid a lot of smoke, wine or irritant food. Osteoporosis can use vitamin D. exercise can promote blood circulation, improve heart and lung function, maintain muscle, bone toughness. It is useful to anyone, lupus is no exception (walking, qigong) do not fatigue, but joint inflammation is not suitable. At the same time to avoid the sun. The lupus patient sensitivity to the sun, is the beta wavelength ultraviolet caused, should try to avoid sunshine. Do not stop hormone or immunosuppressive drugs.
2. diet adjustment
Lupus nephritis patients should not eat or eat less with enhanced light sensitive effect of food, such as figs, milk vetch, rape, celery and yellow Bullacta, such as food should avoid sunlight. Mushrooms, mushrooms and some foods such as letinous edodes dyes and tobacco will have a potential role in induced systemic lupus erythematosus. Also try not to eat or eat less. The kidney damage in patients with systemic lupus erythematosus often have a lot of protein loss in the urine, can cause hypoalbuminemia, it is necessary to add sufficient quality protein, can drink milk, eat soy products, egg, meat, fish and other protein rich food system. Patients with SLE activity less, poor digestive function, should eat light digestible food, should not eat greasy food containing more fat. And patients with systemic lupus erythematosus long-term use of corticosteroids, caused by steroid sugar Urinary disease and Cushing syndrome, we should properly control the appetite, eat less sugary foods. Besides corticosteroids or renal damage in patients with easily lead to water and sodium retention, causing swelling, the low salt diet. At the same time, but also actively prevent glucocorticoid caused by osteoporosis; eat vitamin rich. Vegetables and fruits.