"Kidney Involvement & Lupus" Chat Transcript for Dr. Brad Rovin
Moderator
Good afternoon. The Lupus Foundation of America is pleased to welcome Dr. Brad Rovin.
Dr. Rovin, FACP, FASN is Professor of Medicine and Pathology at the Ohio State University College of Medicine. He is the Director of the Division of Nephrology, and is also the Director of the Fellowship Program in Nephrology at Ohio State. Dr. Rovin has been at Ohio State University for 19 years, and has been recognized by Best Doctors® for his work in the area of glomerular diseases.
Dr. Rovin received his bachelor of science in chemical engineering from Northwestern University, followed by his doctor of medicine from the University Of Illinois College Of Medicine. He completed a residency in internal medicine at Barnes Hospital in St. Louis, and a fellowship in nephrology at Washington University.
Dr. Rovin’s research interests include the pathogenesis of kidney inflammation. He has studied the molecular regulation and expression of chemokines in the kidney during glomerulonephritis. He has applied these findings to the study of kidney injury in patients with lupus nephritis. He and his colleagues at Ohio State have followed a large cohort of SLE patients prospectively in the Ohio SLE Study, and have investigated the genetic and environmental factors responsible for lupus flares. His current research focuses on biomarker discovery in an effort to predict future renal lupus flares and initiate treatment earlier to avoid permanent kidney damage. He is also involved in most of the major clinical trials testing new therapies for SLE nephritis.
We welcome Dr. Rovin, and thank him for joining us this afternoon.
Moderator
Without further delay, let's begin. The first question comes to us from Stoneham, MA. I have "significant" scarring from nephritis. Is this permanent and can it be reversed yet?
Dr. Rovin
Scarring in the kidney from lupus nephritis or any other inflammatory kidney disease currently cannot be reversed. There are some animal studies in which scarring has been ameliorated, but nothing applicable to human treatment yet. The current focus of therapy is to prevent further scarring, generally by controlling blood pressure and through the use of anti-hypertensive agents that disrupt the renin-angiotensin system, which include angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB).
Moderator
I have been spilling +1 protein in my urine for 6 years. My 24 does not ever seem to be over 600mg. My doctor isn't concerned because my creatinine is always normal. But I'm worried. Should I request a biopsy or just continue to watch this? -- Detroit, MI
Dr. Rovin
The fact that your creatinine has been normal and unchanged over several years suggests that you have not suffered significant kidney damage, which is good. However, even 600 mg of protein a day could predispose you to progressive kidney injury. Your doctor should try to lower this proteinuria, preferably below 300 mg/day. This could be done with blood pressure control, low salt diet, and they use of ACE inhibitors or ARBs. If these maneuvers are not successful a kidney biopsy could be warranted to see exactly what is going on in the kidneys, and if this needs accelerated immunosuppression.
Gina
Can a person with lupus drink alcohol beverages, or will this increase the effects of lupus?
Dr. Rovin
There is no evidence that alcohol consumption will worsen lupus nephritis. Clearly consumption should be done in moderation. One issue to consider is that if alcohol consumption is due to stress, that stress itself may be a factor in inducing flare of lupus or lupus nephritis.
Lin4031
My rheumatologist has expressed concern that my prednisone dosage may not be sufficient to prevent kidney problems. I am currently taking 7.5 mg daily as well as 400 mg daily of Plaquenil for my lupus. In addition, I take a number of other medications for other medical problems including arthritis, hypogammaglobulinemia, fibromyalgia, chronic bronchitis, and irritable bowel syndrome. I have had only two kidney infections in the past two years.
Dr. Rovin
One of the goals of all of us who treat lupus is to minimize or get patients off immunosuppressive medications if possible. We do not maintain immunosuppression in patients in an effort to protect the kidneys per se. The idea is to treat the disease manifestations adequately, have the patient go into remission and to maintain that remission for at least some lengthy period of time, and then taper down the medications. So for example in nephritis we will treat aggressively with immunosuppression, usually including steroids, and then as the signs and symptoms of nephritis decline, we will place the pateint on maintenance immunosuppression for at least one year after remission. At that point our practice is to begin to taper off the immunosuppresion including steroids. My colleagues and I have been successful in getting several patients off all medications except Plaquenil, and they have not had flares of their nephritis.
Moderator
Hello, I live in the Caribbean and have had lupus for 1 year now. My GP has found protein in my urine at +3. What does this mean and what steps can I take to prevent further damage, if any?
Dr. Rovin
If your GP has found 3+ protein in your urine in the setting of lupus, you need to see a kidney doctor quickly. They will collect a 24-hour urine to determine the amount of protein you are losing each day. It will likely be a significant amount. They will then need to do a kidney biopsy to see exactly how the lupus is affecting your kidney, and afterward they will likely treat you with some form of immunosuppression appropriate for the type of kidney disease you have.
Moderator
My rheumatologist has requested blood tests. I do not have high blood pressure, just the butterfly rash. What could have caused this new development could it be the sun, my diet or exposure to the rays for an old computer recently? -- Kingston, Jamaica
Dr. Rovin
I agree with your doctor in getting blood tests to check for lupus. The butterfly rash could be a clinical sign of this disease. We are not sure what causes lupus, but ultraviolet radiation exposure from the sun can trigger flares of the disease, and so could bring out a rash in sensitive individuals. It is likely that other environmental exposures can trigger flares. I am not certain that an old computer would do that however.
Rano0ody
What is the good diet for people who have lupus? Would you please provide us by an ideal diet program?
Dr. Rovin
In terms of lupus nephritis, the diet we recommend is based on the level of kidney function as well as the level of protein in the urine. For example, patients with lupus nephritis often have a large amount of protein in their urine. In addition to controlling blood pressure which can help reduce proteinuria, we like to decrease the salt intake because excess sodium will drive more proteinuria, and this could be harmful to the kidney itself. We generally recommend a 2 gram sodium restriction. In patients who have a lot of protein in the urine, they often have increases in their cholesterol and this can be a risk factor for cardiovascular disease. As you may know, patients with lupus are in general at increased risk for cardiovascular disease because of the SLE, so we would want a diet low in cholesterol. Patients with advanced renal insufficiency may benefit for a mild protein restriction which in other types of kidney disease is thought to slow the progression toward end-stage kidney disease.
Moderator
How does lupus affect your kidneys? I've been having trouble with infections and trouble urinating. My fluid intake is a lot but I can only go bathroom once or twice a day. What can be wrong with me? -- Dinuba, CA
Dr. Rovin
Lupus affects the kidneys by causing deposits of antibodies in the kidneys, which provoke an inflammatory response. This injures the kidney and causes blood and protein to appear in the urine, and sometime kidney failure. Generally it does not cause kidney infections or trouble getting the urine out. Some of the medications used to treat lupus could suppress your immune system and make infections more likely. I am not sure why you have trouble urinating.
Wisepam
I was diagnosed with lupus nephritis in 1993 at the age of 20. I was treated with prednisone and Cytoxan. I was stable for many years and 2 pregnancies, living with approx 20% kidney function. By 2005 my kidneys had further deteriorated where I was in need of dialysis. I was on dialysis 1.5 years till I received a deceased donor kidney in May 2007. I have heard it is uncommon for lupus to "attack" the foreign kidney … is this true? Also approx. how many people do receive transplants due to lupus?
Dr. Rovin
It has been thought that SLE nephritis does not recur very often in patients who have had a kidney transplant. While many people with a transplant will not experience the disease in their transplanted kidneys, we do see patients where it does recur. Therefore it is always a good idea to have your lupus doctor work with your transplant physician to make sure that they are on top of your case should any abnormalities appear that would suggest SLE in the kidney again. Obviously patients who have transplants are on lifetime immunosuppression, and one of the side benefits of this may be a lesser incidence of active lupus. In terms of people receiving transplants due to lupus, I think about our own SLE population, and I would say that we have fairly successful in avoiding end-stage kidney disease in many patients, however of those who are approaching the need for dialysis, all are referred for transplant if they are eligible. None of us feel that having lupus is a contraindication to transplant.
Moderator
I would like to know how anti-dsDNA plays a role in Kidney and Lupus, and if you do have anti-dsDNA does that make you more prone to kidney problems. -- Kansas City, MO
Dr. Rovin
Double-stranded DNA antibodies are a hallmark blood test for lupus. Antibody complexes of nuclear material plus anti-DNA antibodies could deposit in the kidneys and cause renal injury. It has been thought that the presence of these antibodies in the circulation correlated with lupus kidney flares. However, we and others find that this association is not very strong. That is, you can have significant kidney disease activity and have no detectible anti-dsDNA, or have anti-dsDNA without kidney disease activity.
Moderator
I have heard that at least 40 percent of lupus patients have or will have kidney involvement. Can kidney involvement occur after having lupus for many years? -- Rock Hill, SC
Dr. Rovin
40% or more of patients with SLE do have kidney involvement. While this usually does occur early in the course of the disease, it could also happen late, after several years of lupus.
sfaina
For years I've looked to the results of my urine tests to monitor kidney problems. Now although my urine is fine, blood results show low Glomular Filtration Rate and slightly high for creatinine. What does this mean in relation to the health of my kidneys?
Dr. Rovin
The glomerular filtration rate (GFR) is a measure of kidney function, and lower means worse kidney function. The serum creatinine is a reflection of GFR. The fact that your GFR has declined, despite a good urine test is concerning. It really depends on what has been defined as good. Even proteinuria of 1 gram per day, while certainly better than 5 grams/day, can result in chronic kidney injury if of prolonged duration. There can also be other things that can affect the kidneys, like uncontrolled blood pressure, than can drive chronic kidney injury even if the lupus is well controlled.
One thing that your doctor may need to do is to consider a repeat kidney biopsy if you are having progressive renal insufficiency in the face of no apparent lupus nephritis activity. This could find occult activity that would necessitate more immunosuppression, or it could show scarring from old injury that is progressing. Nonetheless it could point to a direction of therapy to slow progression and maintain kidney function for as long as possible.
Moderator
How do kidney stones affect lupus?
Dr. Rovin
Kidney stones can certainly occur in patients with SLE or SLE nephritis, however I do not believe they would predispose to flare. I also have not observed a higher incidence of stones in my patients with nephritis compared to other groups. The best way to prevent stones is to dilute the urine as much as possible, and that usually means increasing fluid intake. Consult your doctor before doing so, because some patients with heart disease or kidney disease need to be on fluid restriction for example.
Pam's Dad
Are there any new drugs or treatments for lupus nephritis in the pipeline?
Dr. Rovin
The usual therapies of lupus nephritis are steroids plus either MMF or cyclophosphamide. There are several on-going clinical trials looking at unique biologic therapies for nephritis to decrease the use of steroids and cytotoxic agents as above because of their severe side effects. None of the trials yet have published definitive data, but a very large trial using anti-B cell therapy should have their analysis out this spring. The lupus community is hopeful that these results will be positive. If not several new trials with other types of therapy are getting underway, and at least in the laboratory these therapies have been effective in animal models of lupus kidney disease. We remain optimistic that we will find new drugs soon.
biene
I have been on Imuran for 2 1/2 years. How does this drug or others like it effect the kidneys long-term?
Dr. Rovin
Imuran over the long-term should not have a detrimental effect on the kidneys. This medication has been used in transplant for years so we know how people do long term with it. The same is true of MMF, and this is a drug still used in transplant for the patient's lifetime.
Rere
In lupus patients, is high blood pressure a sign that your kidneys are acting up?
Dr. Rovin
High blood pressure should prompt your doctor to look careful at the kidneys and rule out activation of lupus nephritis. Sometime the nephritis will cause abnormalities in the urine, but these are not obvious unless the urine is examined. On the other hand, if the kidney disease is active and increase blood pressure, this could be the first thing that someone notices, because blood pressure is almost always checked when you see any physician.
Andybird
How often should I get my urine tested? Sometimes my urine is a darker color (like weak tea) should I be worried about this. I don't have other symptoms.
Dr. Rovin
If you have SLE, I would recommend that your doctor check your urine for protein and blood at least once a year. If you have had nephritis with your lupus then I would suggest checking the urine at least twice a year, but I would be more comfortable if it was done quarterly. This would hopefully alert the physician to issue early in the course so that treatment could be started quickly to preserve kidney mass. Dark urine generally simply reflects concentration of the urine which is a normal function of the kidneys depending on your state of hydration. If you were to see blood in the urine, which is not subtle, then tell your doctor. Similarly if your urine has lots of bubbles in it, it could be a sign of protein so that also deserves a closer look.
april
Is it always the ratio between protein and creatinine or could just the amount of protein signal a problem?
Dr. Rovin
The protein to creatinine ratio in the urine is a measure of total daily protein excretion. We believe that the best measure for quantifying proteinuria is measure the P/C ratio from a 24-hour urine collection, or an intended 24-hour collection. Our group, with colleagues from Johns Hopkins, has recently finished a study looking at smaller time intervals for accuracy and this will hopefully be published soon. However, the 24 hour urine total protein measurement will also give a lot of information about the kidney, and if elevate will signal a problem that needs rapid attention.
Moderator
That is all the time we have for today’s chat. Thank you to Dr. Brad Rovin for joining us.
Our scheduled chat for April 8 has been canceled, and we are hoping to schedule something else for April. Please stay tuned.
Otherwise, please join us Wednesday, May 13 at 3 p.m. Eastern for our guest Dr. Robin Brey, who will discuss Neurology / Central Nervous System & Lupus.
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