When does amyloidosis complicate systemic lupus erythematosus?

Breakdown of Immune Tolerance in Systemic Lupus Erythematosus by Dendritic Cells

Dendritic cells (DC) play an important role in the pathogenesis of systemic lupus erythematosus (SLE), an autoimmune disease with multiple tissue manifestations. In this review, we summarize recent studies on the roles of conventional DC and plasmacytoid DC in the development of both murine lupus and human SLE. In the past decade, studies using selective DC depletions have demonstrated critical roles of DC in lupus progression. Comprehensive in vitro and in vivo studies suggest activation of DC by self-antigens in lupus pathogenesis, followed by breakdown of immune tolerance to self. Potential treatment strategies targeting DC have been developed. However, many questions remain regarding the mechanisms by which DC modulate lupus pathogenesis that require further investigations.

Amyloid A amyloidosis and systemic lupus erythematosus

Amyloid A (AA) amyloidosis occurs secondary to long-standing inflammation and causes nephropathy and various internal manifestations, which leads to mortality. It is very rare in some rheumatic diseases, such as systemic lupus erythematosus (SLE). Therefore, there are few articles that report AA amyloidosis in SLE. This article focuses on the previously reported cases of 24 patients with SLE that are complicated by AA amyloidosis, and on the underlying mechanisms.

Proliferative lupus nephritis in a patient with systemic lupus erythematosus and longstanding secondary amyloid nephropathy

Secondary amyloidosis is an unusual complication of systemic lupus erythematosus (SLE). We report the case of a 60-year-old woman with SLE and secondary amyloidosis who developed class III proliferative lupus nephritis 13 years after the onset of amyloid nephropathy. The patient was treated with mycophenolate mofetil (1.5 g/day) with a significant improvement in proteinuria.

The role of kidney biopsy in the management of lupus nephritis

PURPOSE OF REVIEW

This review evaluates the role of kidney biopsy as a tool in the diagnosis, prognostication and therapeutic management of lupus nephritis. The renal biopsy is the only method available for diagnosing and classifying lupus nephritis. However, disagreements persist regarding the appropriate role of a renal biopsy in the management and identification of predictors of short and long-term outcomes.

RECENT FINDINGS

Recent modifications to the classification of lupus nephritis, the emergence of newer scoring indices, and the availability of a variety of therapeutic options predicate a reassessment of the role of the renal biopsy in the management of lupus nephritis, especially for high-risk patients.

SUMMARY

Despite some controversy, the renal biopsy has been shown to provide information over and above that provided by the clinical variables, and remains a pivotal element in optimizing therapy and the rational management of lupus nephritis.

Renal and systemic amyloidosis in systemic lupus erythematosus

A young male presented with oral ulceration for two years; swelling face and feet of seven days duration; diffuse goiter without signs of thyroid disease; normocytic normochromic anemia, thrombocytopenia, deranged renal functions, albuminuria of 2.5 g/24h with active urinary sediment. ANA and anti-ds DNA were positive, sonography of abdomen suggested medical renal disease. Testing for HIV, HBV, VDRL, CRP, rheumatoid factor, p-ANCA and c-ANCA were negative. Thyroid hormone assays were normal. Kidney biopsy done to stage lupus nephritis did not show any evidence of lupus involvement but staining for SAA amyloid was positive. Subsequent biopsies from the liver and rectum also stained positive for amyloid. Diagnosis of "Systemic lupus erythematosus with renal and systemic secondary amyloidosis with euthyroid diffuse goiter" was made. The case is being reported and discussed because of the interesting and rare association between amyloidosis and systemic lupus erythematosus.

Nonlupus nephritides in patients with systemic lupus erythematosus: a comprehensive clinicopathologic study and review of the literature

Renal biopsy specimens from patients with systemic lupus erythematosus (SLE) rarely show changes that are pathogenetically and morphologically unrelated to SLE. The morphology and behavior of these nonlupus nephritides are not well known. Two hundred fifty-two renal biopsies performed on 224 patients with SLE collected from 3,036 native kidney biopsies performed between 1975 and 1998 were reviewed, and those that showed nonlupus nephritides (index biopsies) were selected for studies. Thirteen biopsy specimens with nonlupus nephritides were identified in 13 patients, who belonged to 3 clinically distinct groups. Group I included 6 patients in whom SLE was diagnosed at the time of index biopsies. The index biopsies in these patients showed focal segmental glomerusclerosis (FSGS; 3 cases), Immunoglobulin (Ig) M nephropathy (1 case), and thin basement membrane disease (1 case). The diagnostic features for FSGS included segmental sclerosis involving at least 1 glomerulus, absence of lupus nephritis or other conditions that may cause nonspecific segmental sclerosis of glomeruli such as ischemia or nephrosclerosis, and nephrotic-range proteinuria. There was uniform, global, diffuse and marked thinning of the glomerular basement membrane in the case of thin basement membrane disease. Group II included 3 patients in whom SLE was diagnosed 2 to 9 years before the time of index biopsies and SLE was active at the time of biopsy. The index biopsies in these patients showed FSGS (2 cases) and hypertensive nephrosclerosis (1 case). Group III included 4 patients in whom SLE was diagnosed 5 to 36 years before the time of index biopsies and SLE was inactive at the time of biopsy. The index biopsies in these patients showed 1 case each of amyloidosis, FSGS, hypertensive nephrosclerosis, and allergic acute tubulointerstitial nephritis. Previous renal biopsies, performed in 5 patients, showed IgM nephropathy (1 case), diffuse proliferative lupus GN (1 case), focal proliferative lupus GN (1 case), and mesangial proliferative lupus GN (2 cases). Follow-up biopsies, performed in 3 patients, confirmed the diagnosis of FSGS (2 cases) and hypertensive nephrosclerosis (1 case) noted in the index biopsies. Nonlupus nephritides may occasionally be encountered in SLE patients, regardless of clinical or serologic disease activity. These renal lesions display a broad morphologic spectrum in which FSGS seems most frequent. Renal biopsy plays a crucial role in identifying these lesions, which may have prognostic and therapeutic implications distinct from those of lupus nephritis.

Systemic lupus erythematosus and amyloidosis

Amyloidosis in association with Systemic Lupus Erythematosus (SLE) has rarely been reported. We report a patient with "SLE" and Amyloidosis presenting with recurrent bloody diarrhea and review the relevant literature.