Chen T K, Gelber A C, Witter F R, Petri M, Fine D M
Division of Nephrology
Division of Rheumatology.
Lupus. 2015 Feb;24(2):147-54. doi: 10.1177/0961203314551812. Epub 2014 Sep 23.
The differential diagnosis of proteinuria and hematuria in pregnancy is broad and includes active lupus nephritis. Identification of the correct diagnosis often has a profound therapeutic impact on not only the mother but also the fetus. To date, relatively few reports exist on the role of renal biopsy during pregnancy among women with systemic lupus erythematosus (SLE). We present a case series of 11 pregnant women with SLE who underwent a renal biopsy to evaluate a presumptive flare of lupus nephritis. The electronic medical record was retrospectively analyzed for pre-biopsy serum creatinine, proteinuria, hematuria, antinuclear antibodies (ANA), and antibodies to double-stranded DNA (anti-dsDNA); histologic findings on renal biopsy; and the clinical course of each mother and fetus. From 2001 to 2012, 11 pregnant women with SLE flares during pregnancy underwent a renal biopsy at an academic tertiary medical center. At the time of biopsy, median gestational age was 16 weeks (range 9 to 27), median serum creatinine was 0.6 mg/dl (interquartile range 0.5 to 0.9), six (55%) had hematuria, and all had proteinuria >500 mg/24 hours. Proliferative lupus nephritis was found in 10 (91%) of 11 biopsies (five with ISN/RPS Class III; five with ISN/RPS Class IV). All but one individual underwent a change in management guided by information gleaned from renal biopsy. No apparent biopsy-related complications occurred to mother or fetus. Three women elected to terminate their pregnancy; although many factors were involved, the findings on renal biopsy informed the decision-making process. Among the remaining cases, there were three pre-term deliveries, one fetus with complete heart block, one in utero demise, and one maternal death. Renal biopsy is helpful at informing the management of patients with lupus nephritis during pregnancy.
妊娠期蛋白尿和血尿的鉴别诊断范围广泛，包括活动性狼疮性肾炎。正确诊断不仅对母亲而且对胎儿的治疗往往有深远影响。迄今为止，关于系统性红斑狼疮（SLE）女性妊娠期肾活检作用的报道相对较少。我们报告了一组11例妊娠期SLE患者的病例系列，她们接受了肾活检以评估疑似狼疮性肾炎发作。对电子病历进行回顾性分析，以了解活检前的血清肌酐、蛋白尿、血尿、抗核抗体（ANA）和双链DNA抗体（抗dsDNA）；肾活检的组织学结果；以及每位母亲和胎儿的临床病程。2001年至2012年期间，11例妊娠期SLE发作的孕妇在一家学术性三级医疗中心接受了肾活检。活检时，中位孕周为16周（范围9至27周），中位血清肌酐为0.6mg/dl（四分位间距0.5至0.9），6例（55%）有血尿，所有患者蛋白尿均>500mg/24小时。11例活检中有10例（91%）发现增殖性狼疮性肾炎（5例为ISN/RPS III级；5例为ISN/RPS IV级）。除1例患者外，所有患者均根据肾活检获得的信息改变了治疗方案。未发生明显的与活检相关的母婴并发症。3名女性选择终止妊娠；尽管涉及许多因素，但肾活检结果为决策过程提供了参考。在其余病例中，有3例早产，1例胎儿患有完全性心脏传导阻滞，1例宫内死亡，1例产妇死亡。肾活检有助于指导妊娠期狼疮性肾炎患者的治疗。
