20F Lupus Nephritis Relapse 2 Weeks, Seizures and Nephritis Recovered, Telangana PaJR
24-12-2024
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
PPM 3 - Patient suffering form pain abdomen currently am unable to answer her call. Please any volunteer or pg o
https://08arshewarpavankumar.blogspot.com/2022/09/20-yr-female-with-bl-pedal-edema.html?m=1
r intern could help her 🙏🏻
PPM 4 - Unable to call her sir. Some problem from her end I guess. Messaged her.
PPM 1 - 👍
PPM 4 - The patient came to OPD just now.
PPM 1 - Let's admit her. I can review her in the ICU AMC now.
30-12-2024
Caretaker - Good afternoon sir and madam. My patient is having pedal edema and there is swelling in her face too.
PPM 3 - Can you please share the image of her feet.
PPM 1 -
Looks like her renal proteinuria may have increased.
We'll need to get her serum albumin and urine for 24 hour protein and creatinine
Let's ask her to share the image of her kidney medications
I guess she was on tablet azathioprine and prednisolone and the prednisolone dose had been brought down to the minimum.
Caretaker - 
PPM 3 - This is gross.
The patient has to come to the hospital and has to be admitted for 1-2 days. We have to get done 24hr urine proteins test. This test is very essential. With this test the medication dosage will be changed.
Caretaker - Okay sir.
PPM 1 - Please ask her to share her current tablet dosages and when did she taper them off.
PPM 3 - Please share the pics of present medication of your patient. Since when is she taking the medicines?
Caretaker - This yellow tab taken in the afternoon 👇 5mg in the morning, 2.5 in the night sir.
PPM 1 - Yellow tablet packet picture to see name and dose.
Caretaker - 50 mg.
PPM 3 - AZA 50mg sir.
PPM 1 - Was she always consuming 50 mg or was it reduced after she developed the hydropneumothorax?
02-01-2025
PPM 3 - Just received a call from Patient advocate, patient is having constipation with no flatus, No urine output and Generalised body swelling. In apprehension he got a syrup to relieve her constipation but still stools not passed. He will be visiting ER in a while.
@PPM4 @PPM5 @PPM6 @PPM7 @PPM8 @PPM9 Please look into this.
PPM 1 - Yes hoping to see her soon. Will be in OPD.
They can even reach directly to our OPD.
Reviewed in OPD:
Anasarca
Other findings wnl
Anuric since morning
Constipation since morning
Plan
Admit in wards
Monitor intake output.
PPM 3 - 24h UPCR sir..?
PPM 1 - Yes once the urine comes out.
Reviewing in OPD
Currently on lowest dose prednisolone 5mg and 2.5 mg along with Azathioprine 50 mg for her Lupus nephritis
Anasarca
BP 140/80
Other findings wnl
Anuric since morning
Constipation since morning
Plan
Admit in wards
Monitor
intake output
RFT
May need to watch out for RPGN.
PPM 1 - @PPM10 she passed 250 ml of urine (her estimate) spontaneously now!
PPM 10 - 👍
PPM 3 - @PPM5 @PPM4 patient is having agonising pain abdomen, her advocate is apprehensive about her abdominal distension and pain abdomen. Kindly look into this and update please.
PPM 1 - Oh just now?
She didn't have it in the morning or even afternoon?
She's likely having a post infectious IBS and can be put on Buscopan tablets tid and injection Buscopan sos.
PPM 3 - Yes sir 2 min back. He reports pain is worsening.
PPM 1 - @PPM10 share your clinical findings or ask the AMC pg to share here ASAP.
PPM 1 - @PPM11 if you are there in AMC just examine her abdomen and share the findings.
PPM 11 - Abdomen is soft and non tender sir.
PPM 1 - 👍
And how is her pain now?
PPM 11 - She is complaining of bloating of abdomen sir
She did not pass stool since yesterday
O/e : abdomen is soft and no tender
Bowel sounds present.
PPM 1 - 👍
PPM 11 - Yes sir after giving inj pantop.
PPM 3 - Thank you. Any intervention to relieve her constipation ..?
PPM 11 - Giving Enema sir.
PPM 1 - 👍
PPM 10 - 
PPM 1 - 👍
03-01-2025
PPM 1 - @PPM10 share the deidentified abdominal ultrasound report here.
PPM 10 - 
PPM 1 -
Now check out figure 4 here 👇
And use our POCUS device to DIY
04-01-2025
PPM 1 - Reviewed in the afternoon:
Current autoimmune inflammatory indicators:
24 hour significant proteinuria 1.2 g suggestive of active glomerular inflammation
Persistent bowel symptoms in this admission and thickening on imaging suggestive of possible IBD
Reviewed the major events in the entire history from September 2022:
1st admission with altered sensorium, serositis, nephrotic proteinuria and ANA +++ suggestive of Lupus and started on high dose steroids with azathioprine as adjuvant and unfortunate anticoagulants (thinking of cardiac embolism)
December 2022
2nd admission with complications of minor IC bleed due to anticoagulant
Lost to follow up in 2023 till June 2024
Not sure if she achieved glomerular remission
Stopped all Rx in December 2023
June 2024 presented with flare of arthritis and proteinuria
Restarted steroids and adjuvants and developed pyopneumothorax because of which immunosuppressives were again quickly tapered off to prednisolone 5mg and Azathioprine 50 mg once daily with poor follow up and this time in Jan 2025 she appears to have developed glomerular injury again along with possible IBD this time!
PPM 3 - 👍
PPM 11 - She had libbmans sacks endocarditis
And once she admitted with Cushing also sir
Her PT INR APTT was also deranged back then, PT was in 100 contributed it to warfarin.
05-01-2025
PPM 1 - Libmanns sacks endocarditis is not an easy diagnosis and definitely needs histopathological confirmation and in her case as well as most cases that isn't possible and it's largely an autopsy pathology learning point.
Yes she did have side effects of steroids that are very common trade offs unlike her anticoagulant trade off where the benefit risk ratio needed to be better balanced and I would classify it as an over-testing leading to LSE and cerebral embolism diagnosis leading to overtreatment with anticoagulants
Yes the PT INR was the marker of the overtreatment delivered along with the MRI brain hemorrhages that were luckily detected early due to serendipitous sequence of events that brought her back in altered sensorium during her second admission.
PPM 11 - 👍
PPM 2 - I remember we did see some vegetations and a profound MR on the echo, first time?
PPM 1 - Unfortunately the echocardiography video wasn't archived?
PPM 2 - I believe it was archived. @PPM3 or @PPM12 should be aware.
PPM 3 - 
PPM 3 - Missed video but captured this for clinical meet presentation. Her first admission echo image.
Retrieved from
Without the mitral valve Doppler it's difficult to say if the MR visible on CFM is trivial or significant.
However valvulitis is probable looking at the video. So as mentioned before it's a difficult diagnosis and the probability can only be enhanced with histopathology.
Not sure about the vegetations although again yes there is a suspicious shadow in the inner surface of pml
Fantastic to see this really!
Whatever case reports and data we capture and archive may become more valuable with the passage of time! @Case reporters.
08-01-2025
PG - Sir her BP in the morning is 160/100
1 pm - 170/100
5 pm - 170/100
Does she nedd any hypertensive sir?
PPM 1 - Yes.
Start tablet Telmisartan as it will also be available from her local PHC.
Please share her hourly BP chart.
12-01-2025
PA -
PPM 1 - Can start Tablet Lasix 40 mg once daily.
Please share the other medicines this patient is taking.
PA - 
PPM 2 - No quality or reliable data comparing Dexa vs MP. May have to take some expert opinions I guess.
PPM 1 - 👍
Caretaker - How will the pedal edema subside?
PPM 4 - Should take lasix 40mg daily.
PPM 1 - 👍
Tablet lasix to tide over the cosmetic crisis
Prednisolone and azathioprine will take a few weeks to show efficacy.
Caretaker - The patient had taken 30mg lasix in the afternoon.
PPM 1 - Start taking 40mg lasix.
16-01-2025
PPM 1 - How is the patient's pedal edema?
17-01-2025
PPM 1 - Reviewed the patient today in ICU.
Has started having severe epigastric abdominal pain again since yesterday
Along with vomiting
On examination:
Abdomen soft
Working diagnosis:
Drug induced gastritis
Plan @PPM7 @PPM8 @PPM12
Hold the tablet prednisolone for a few days
Repeat LFT
Serum creatinine
Urine for 24 hour protein and creatinine
Temporarily withhold
[17/01, 17:04]: Everytime since last few years when she developed florid proteinuria she would clinically go into remission (although not documented in 24 hour values, the nearest was probably 700 mg recently during last admission when we were battling the ravages of her pyopneumothorax) following which after the steroids were tapered due to the infection, she again developed this florid proteinuria since two weeks which doesn't seem to be responding to the 30 mg of prednisolone this time, which is on the contrary producing side effects!
18-01-2025
PPM 1 - Update from the ward.
PPM 1 - Hypoalbuminemia as expected due to her nephrotic syn flare. Steroid induced gastritis has actually made us withhold steroids at this juncture and azathioprine dose also has been reduced! @PPM5 @PPM2 this is the patient both of you managed three years back in the first encounter with us.
PPM 2 - 👍
PPM 1 - Glomerular injury predisposes to Hypertension.
PPM 2 - Are any alternatives being considered?
Does she need a pulse dosing again?
PPM 1 - This time she also appears to have an imaging finding of inflammatory bowel dose in her colon since last admission which appears to be persistent and they can't afford a colonoscopy.
Yes likely. Although iv dexa will be less taxing perhaps.
PPM 2 - I understand the imperative for this although aren't the best outcomes seen with the reliable Methylpred?
I understand each vial costs north of 1k.
PPM 1 - That's a lot.
PPM 2 - To save a kidney?
And consequently human capital?
PPM 1 - Are their studies that dexamethasone can't?
Let's try seeing if there are studies to support that imperative.
PPM 2 - Will let the treating team share.
PPM 1 - 😂
PPM 1 - 👍Which expert worth his salt would be spending time working in low resource settings treating lupus nephritis with dexa instead of MP?
We do have one such non expert generalist's notes documented possibly in tabula rasa. Will try to search and share.
PPM 2 - PPM 1.
20-01-2025
PPM 1 - Update?
Is she getting discharged?
Any repeat 24 hour protein creatinine results in this admission?
Is she on physiological doses of her previous 30 mg prednisolone that had to be withheld due to suspected gastritis?
PPM 4 - Yes sir
Planning for discharge today
Pedal edema and abd distension subsided sir
No pain abdomen nausea and vomitings
She is taking food as before
We stopped prednisolone and azathioprine for the last 3 days sir
Shall we put her back on those and discharge today sir?
PPM 1 - Calculate the actual GFR using the urinary creatinine. @PPM14 @SE can you help?
PPM 13 - 
PPM 16 - What was her serum creatinine value??
PPM 4 - 
PPM 1 - 👍
PPM 7 - Creatinine is 0.8mg/dl sir.
PPM 1 - But remember for GFR calculation from urinary creatinine (this is not e GFR) you need to use the urinary creatinine, the 24 hour urinary volume and other parameters in the formula.
PPM 14 - Ok sir.
PPM 7 - 
PPM 7 - Sir is this the formula, you are talking about?
PPM 1 - Yes this appears to be the one
Any more literature on how it was derived?
What's the GFR as per this formula?
21-01-2025
EMR SUMMARY
Age/Gender : 23 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 17/01/2025 03:31 PM
Name of Treating Faculty
DR Assistant Professor, DR. PG Y3, DR. PGY2
Diagnosis
1. DRUG INDUCED GASTRITIS? ORAL STEROIDS INDUCED
2. LUPUS NEPHRITIS WITH FLARE
3. INFLAMMMATORY COLITIS
4. K/C/O SYSTEMIC LUPUS ERYTHEMATOSIS [SLE] SINCE 4 YEARS
Case History and Clinical Findings
C/O PAIN ABDOMEN SINCE YESTERDAY NIGHT C/O VOMTINGS SINCE TODAY MORNING HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1DAYS AGO,THEN SHE DEVELOPED PAIN ABDOMEN SINCE YESTERDAY NIGHT AT EPIGASTRIC REGION TENDERNESS PRESENT ASSOCIATED WITH VOMITINGS SINCE TODAY MORNING THREE EPISODES, NON BILIOUS, NON PROJECTILE,NON BLOOD STAINED ,WATER AS CONTENT
NO AGGRAVATING AND RELIEVING FACTORS ASSOCIATED WITH NAUSEA
H/O PEDAL EDEMA AND FACIAL PUFFINESS SINCE 25 DAYS
NO H/O FEVER, COLD, COUGH, ALLERGIES, CHEST PAIN, PALPITATIONS, SWEATING, SOB, BURNING MICTURITION, CONSTIPATION
PAST HISTORY:
K/C/O SLE , LUPUS NEPHRITIS AND INFECTIVE COLITIS N/K/C/O DM II, TB, EPILEPSY, ASTHMA, CVA,CAD
FAMILY HISTORY:
INSIGNIFANCT PERSONAL HISTORY:
SLEEP- ADEQUATE APPETITE-NORMAL DIET-MIXED
BOWEL AND BLADDER MOVEMENTS-REGULAR ADDICTIONS-NIL
GENERAL PHYSICAL EXAMINATION:
TEMPERATURE-AFEBRILE BP-160/100MMHG
PR-156BPM RR-22CPM
SPO2-98%AT RA
MILD BILATERAL PEDAL EDEMA PRESENT [PITTING TYPE]
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION CVS - S1, S2 HEARD, NO MURMURS.
RS- B/L AE - PRESENT, NVBS, NO ADDED SOUNDS.
P/A - SOFT, TENDERNESS AT EPIGASTRIC REGION, NO ORGANOMEGALY, BOWEL SOUNDS PRESENT
CNS-NO FOCAL NEUROLOGICAL DEFICIT LOCAL EXAMINATION:
PER ABDOMENSOFT, TENDERNESS AT EPIGASTRIC REGION, BOWEL SOUNDS PRESENT, NO ORGANOMEGALY
NO GUARDING, NO RIGIDITY NO SCARS
Investigation
Anti HCV Antibodies - RAPID 17-01-2025 05:54:PM Non Reactive HBsAg-RAPID 17-01-2025 05:54:PM Negative
RBS ON 17/1/25 -70 mg/dl. HEMOGRAM ON 17/1/25
HAEMOGLOBIN 8.2 gm/dl TOTAL COUNT 9,200 cells/cumm NEUTROPHILS 84 % LYMPHOCYTES 11 % EOSINOPHILS 04 % MONOCYTES 01 % BASOPHILS 00 % PCV 24.2 vol % M C V 84.6 fl M C H 28.7 pg M C H C 33.9 % RDW-CV 15.3 % RDW-SD 47.2 fl RBC COUNT 2.86 millions/cumm
PLATELET COUNT 3.05 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia
LIVER FUNCTION TEST (LFT) 17-01-2025 05:54: PM Total Bilurubin 1.07 mg/dl 1-0 mg/dl direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl SGOT(AST) 15 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0
IU/LALKALINE PHOSPHATASE 84 IU/L 98-42 IU/LTOTAL PROTEINS 3.9 gm/dl 8.3-6.4
gm/dl ALBUMIN 2.12 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.19
COMPLETE URINE EXAMINATION (CUE) 17-01-2025 05:54:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN +++SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS 3- 4CRYSTALS Nil CASTS Nil amorphous DEPOSITS Absent OTHERS Nil
BLOOD UREA 17-01-2025 05:54:PM 49 mg/dl 42-12 mg/dl
SERUM CREATININE 17-01-2025 05:54:PM 0.8 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 17-01-2025 05:54:PMSODIUM 136 mmol/L 145-136
mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L 24 Hours Urinary Sodium ON 18/1/25 - 220 mmol/day 24 Hr URINE VOLUME : 1,700 ml
24 HOURS URINE PROTEIN ON 18/1/25- 250 mg/day. 24 HOURS URINE CREATININE-1.4 g/day RATIO 0.17URINE VOLUME 1,700 ml
24 Hr URINARYPOTASSIUM ON 18/1/25 - 45.0 mmol/day URINE VOLUME 1700 ml USG DONE ON 17/1/25
IMPRESSION:
LONG SEGMENT CIRCUMFERENTIAL WALL THICKENING OF LARGE BOWEL RIGHT ADNEXAL CYST? RIGHT OVARIAN CYST [REVIEW IN FULL BLADDER] REVIEW USG DONE ON 18/1/25
IMPRESSION:
DIFFUSE BOWEL WALL THICKENING NOTED IN ASCENDING, TRANSVERSE AND DESCENDING COLON WITH A MAXIMUM THICKNESS OF 12-13MM
MODERATE ASCITIS
B/L RAISED ECHOGENICITY OF KIDNEYS
REST OF THE FINDINGS CONSISTENT WITH THE PREVIOUS SCAN.
Treatment Given (Enter only Generic Name)
1. INJ PAN 40 MG IV /OD
2. INJ ZOFER 4 MG IV/ BD
3. INJ LASIX 40 MG IV/ BD
4. INJ. BUSCOPAN IV/SOS
5. TAB. TELMA 20 MG PO/OD/ 8 AM
6. TAB. ZYTANIX 2.5 MG PO/OD 2PM
7. SYP. MUCAINE GEL 10 ML PO/TID
8. 1 ORS SATCHET IN 1 GLASS OF WATER, DRINK 200 ML
9. OINT.THROMBOPHOBE L/A TID
10. MONITOR VITALS AND INFORM SOS
Advice at Discharge
1. TAB. PREDNISOLONE 5 MG PO/OD TO CONTINUE
2. TAB.AZATHIOPRINE 50 MG PO/OD TO CONTINUE
3. TAB. DYTOR 20 MG PO/OD TO CONTINUE
4. TAB.ZYTANIX 2.5 MG PO/OD TO CONTINUE
5. TAB.TELMA 20 MG PO/OD TO CONTINUE
6. TAB.PAN 40 MG PO/OD X 15 DAYS
7. TAB.ZOFER 4 MG PO/SOS
8. SYP. MUCAINE GEL 10 ML PO/TID X 15 DAYS
9. OINT.THROMBOPHOBE L/A TID
Follow Up
REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date
Date: 20/1/25
Ward: FEMALE MEDICINE WARD
Unit: V
21-01-2025
PA - Sir the patient is hungry, can she eat rice?
PPM 1 - Yes that's good to hear that she's feeling hungry
And if possible let her take a balanced Harvard plate.
PA - The patient should eat Fruits, vegetables and cereals.
Can the patient eat non veg?
PPM 1 - She can eat everything like shown below.
25-01-2025
PPM 1 - Update?
What medications is she currently on?
What is her current edema like?
09-02-2025
PPM 6 - Sir the patient got admitted today morning at 6:30 am
With complains of vomitings 2 episodes at 9 pm food material as content, non bilious
Pain abdomen since 10 pm epigastric and umbilical region non radiating pain, pain is getting relieved on lying in prone position
Vitals at presentation
PR: 96/min
BP:120/70 mmHg
RR:22 cpm
Spo2:96% on RA.
PPM 1 - Pancreatitis? Steroid or azathioprine induced?
Why did they not share any updates since 21st January?
"The number of patients treated with azathioprine to cause an episode of pancreatitis was 36 (induction of remission) and 31 (maintenance of remission).The risk of pancreatitis in patients receiving azathioprine across all contexts was 3.80%, compared with a control risk of 0.2% (placebo) and 0.5% (5-aminosalicylic acid agents)."
Unquote
Azathioprine induced pancreatitis usually runs a benign self limited course with rapid disappearance of signs and symptoms upon with drawl of the drug.
Unquote
PPM 6 - On per abdominal examination there was tenderness in umbilical region sir
And the patient was also comfortable on lying in prone position.
USG showed this sir 👆
PPM 1 - Other than inflammatory bowel disease that we had been considering for a few weeks since her first USG few weeks back showed this bowel thickening, the other important pathology to rule out is tuberculosis. @PPM15 do they do free colonoscopy there in Gandhi medical college as this patient is not affordable?
Also @PPM6 can you share the previous latest chest X-rays and sputum AFB and CBNAAT?
Today's chest X-ray.
PPM 1 - Pain relieved by prone position was our initial cue to suspect pancreatitis.
Looks clear.
PPM 6 - Epigastric and umbilical region pain with tenderness in umbilical region along with relief of pain on lying llin prone position or lateral position made me think pancreatitis and she also told if she drinks or eats food abdominal pain is increasing itseems sir.
PPM 1 - 👍
Yes you were on the right track before the ultrasound findings added another layer of complexity
PPM 2 - Are we temporarily withdrawing the drug then?
PPM 1 -
Yes let's keep it on hold till the uncertainty is resolved @PPM14
PPM 6 - Okay sir.
PPM 1 - Update:
Yesterday's history and ongoing meds reviewed.
PPM 1 - Additional Methyl Prednisolone 500 mg iv od planned by @~Ramji today
Let's review the current status of her proteinuria with a 24 hour urine protein and creatinine.
The spot protein creatinine attached here if reliable doesn't suggest an active lupus nephritis
The inflammatory bowel issue needs further investigation with a colonoscopy to rule out tuberculosis.
Let's hold the iv methyl prednisolone till then.
PPM 3 - 👍
PPM 1 - The urine output is not being monitored since admission! This is supposed to be from 9:00AM yesterday to 9:00AM today! But the patient says she voided most of it outside! @PPM6 @PPM9
PPM 16 - Sir diagnosis is clear sir..
It's mesenteric vasculitis, which is suggested by her acute presentation, favored by USG abdomen findings,delay In management can lead to complications like perforation sir...
CT abdomen is more appropriate investigation here if there is any doubt in the diagnosis sir.
PPM 1 - You mean CT angiography?
Get a CT angiography academic free if you suspect mesenteric vasculitis although a negative result will still not rule out micro vasculopathy.
PPM 16 - No sir, CT abdomen to look for signs of vasculitis..
CT angio is not giving us much information since the vessels involved are small vessels..
PPM 1 - What signs do we expect in CT abdomen?
Can we get an Abdominal x-ray to look for any signs of intestinal obstruction?
Currently she doesn't appear to have any signs of intestinal obstruction.
PPM 16 - Vessels prominence, dilated bowel loops, palisade pattern, ascites,bowel wall thickening, double halo sign.
PPM 1 - Bowel thickening present in ultrasound since last two months
Ascites absent
What is the sensitivity of others?
Can one rule out intestinal vasculitis if the CT abdomen is normal?
@PPM9 please get an AxR abdomen ap view ASAP.
PPM 9 - Yes sir.
PPM 16 - Minimal inter bowel fluid is present sir...
PPM 1 - @PPM9 get a surgery opinion ASAP. Wasn't taken by @PPM6 yesterday?
PPM 16 - Ko SF, Lee TY, Cheng TT, et al.: CT findings at lupus mesenteric vasculitis, Acta Radiol 38:115–120, 1997.
Article is not available for free sir, the question to sensitivity may be found in this article sir..
Yesterday we managed her symptoms, while thinking of possible etiologies sir....
PPM 1 - Let's establish that she has intestinal obstruction with an abdominal x-ray and take the surgeons into the loop.
Let's see if a CT abdomen can be done academic free.
PPM 9 - 
PPM 1 - Thanks. Please get this reported by the radiology.
Please share the surgery notes
The abdominal x-ray doesn't look normal.
PPM 9 - Okay sir
The PG said she would look the case now and then will update sir.
PPM 1 - 👍
Evening update:
Progressive azotemia, oliguria since morning
Urea -49 to 87
Creatinine -1.1 to 2.7
PPM 16 - She had significant volume loss since the onset of illness, moreover any oral correction is not tolerated by the patient sir..
Iv volume replacement was inadequate which I have asked to do strictly...
Unless her primary cause is treated, this volume loss in the form of vomiting may continue..
This is my approach towards this case sir as of now...
PPM 1 - Agree.
Can check ivc movement in inspiration and expiration using pocus ASAP @PPM15
What is the primary cause? Unless we do a colonoscopy or CT abdomen that remains uncertain. Any luck with getting it academic free?
PPM 16 - SLE with GI vasculitis (presenting complaint)
PPM 1 - What features of the patient suggest gi vasculitis other than the fact that it's one of the differentials explaining her features of intestinal obstruction?
PPM 4 - Sir its looking like colon cut off sign?
PPM 1 - Partially.
Can't see a distinct cut off
PPM 2 - An early Rigler sign perhaps can help?
11-02-2025
PPM 1 16 - She doesn't have substrate to suspect GI obstruction sir, pseudo obstruction is better differential
She doesn't have colicky pain, abdominal distension
Moreover already USG abdomen is done it features are suggestive of vasculitis, with involvement in 2 different sites, small bowel and large bowel..
All her features are better fitting to vasculitis than obstruction sir..
PPM 1 - What USG features in her suggest vasculitis?
PPM 16 - Wall thickening, mild fluid..
PPM 1 - That can be due to any cause of inflammatory bowel
I'm writing to the MS and director in the staff group for help regarding her CT and colonoscopy.
PPM 16 - I will sponsor her CT sir @PPM9 arrange immediately for CT.
Patient shouldn't know that it's sponsored, if they come to know they expect more free aid...
Try academic free, if necessary I will come to talk...
If not possible, get it done ASAP, I will sponsor..
PPM 9 - Okay sir
PPM 1 - @PPM3 @PPM9 @PPM2 Do you recall how much high dose dexa we had given her last time for her last flare?
👆it may be there in her case reports too in the description box.
PPM 2 - I'm sure it was Methylpred?
PPM 3 - 750 mg methyl pred was given as pulse therapy followed by
Oral steroids, AZA.
PPM 2 - Does she have a lupus flare now? Is Vasculitis an indication for high dose Methylpred?
I recall we do Pred 1mg/kg here.
PPM 16 - It is sir..
PPM 2 - Alright. 👍🏼
Any literature if possible?
PPM 16 - 
Apparently it was given from our AMC stock and out of these two options they paid 900 for the less expensive brand without a receipt.
PPM 9 - Yes sir I spoke with sir
This is from kelley's latest edition sir.
PPM 1 - 
The ml graduations are well visible! Simple and nice container for measuring volume from a discarded NS bottle.
👆Even Prof Vivekananda Jha was a part of our CBBLE at that time!
Afternoon update and timeline by @PPM9
In bed
On iv NS 50 ml/hour and since morning received only 300 ml! Too less? @~Harika
Passed 100 ml just now!
Need
Passed some loose stools right now.
@PPM9 what about the review by Prof Sir?
Rising creatinine trends.
PPM 1 - @PPM17 any luck with the LB Nagar Gastro for colonoscopy?
@PPM3 do you know anyone there in LB Nagar who can help us with the Gastro colonoscopy there?
PPM 17 - No one is answering the call sir i will try again later sir.
PPM 1 - Can talk to NIMs Gastro and our ex UG PG
PPM 3 - One of my batchmate in KHL is now Gastro resident in NIMS sir. Will try him.
PPM 1 - Conversations with NIMs gastro resident and our ex UG PG:
[11/02, 13:12] : Can you help a 20F with intestinal obstruction with inflammatory bowel and AKI in the background of Lupus if we send her to you there just for the colonoscopy biopsy and back?
Off course if you want to admit her and go full length that also is great.
Her case report is here👇
[11/02, 13:22] NIMS Gastro KIMS UG PG: Is she having intestinal obstruction right now sir ?
[11/02, 13:32] NIMS Gastro KIMS UG PG: Sir please ask the patient to come to nims tomorrow to meet sir. I’ll give them appointment for colonoscopy on a later date . Our schedule is full for this week already .
[11/02, 14:53]: Yes since the last few days also with AKI oliguria
Just now she feels slightly better
[11/02, 14:55]: Tomorrow in your OPD? Is it only on Wednesday?
Another 20M we had discussed with you for hypersplenism and possible portal hypertension earlier went to NIMs but couldn't meet you. Not sure which day it was.
I guess I'll have to search my previous Lupus dexa records now.
PPM 1 - 👆Found this but the original udhc.co.in disappeared before we switched to blogspot and I can't access the dexa dose details! She didn't have a bad outcome from what I can recall.
PPM 1 - 👆Finally located the dexa dose we had used!
10 years back similar Lupus patient case report with extensive engagement in tabula rasa (similar to CBBLE PaJR) 👇
[11/02, 15:05] NIMS Gastro Kims UG PG: This week my Opd is on Wednesday and Friday sir. And for next two weeks my Opd is on Tuesday , Thursday and Saturday. They can come on any of these days when she is stable.
[11/02, 15:46] : Our PGs will text you to coordinate.
12-02-2025
PPM 9 - 
PPM 1 - Thanks and total intake output for 11/2/25?
How many stools yesterday?
Bowel sounds?
PPM 9 - Patient was nbm yesterday
And now symptomatically feels better.
No pain abdomen no tenderness
No vomitings
Today - allowing orally
I/o -2100/500ml
Passed 1 episode of stool semi solid in consistency flatus +
Bowel sounds - present
PPM 1 - 👍
@PPM16 can we say that it's her ischemic bowel recovering without any steroid therapy?
PPM 9 - Yesterday methyl prednisolone 500mg was given sir.
PPM 1 - Given at what time?
Yesterday evening?
There was nothing mentioned in the file about it when I evaluated her in the afternoon and she had already recovered by afternoon as per my findings.
Saw this note now! So even when i was evaluating her at this time yesterday the iv 500mg methyl prednisolone was started by ICU PG at 3:00PM and I wasn't even informed by ICU PG about it although both of us were seeing the patient together!
@PPM17 discarded 500 mg in that vial after giving 500 mg from the 1000mg vial
ICU PG thinks as per his observations as ICU PG it's the forced ryles tube insertion followed by removal after 2-3 hours which made her recover.
@PPM9 and @PPM4 think it could have been a pancreatitis which has recovered spontaneously and coincidentally patient also received iv methyl pred at 3:00 PM by which time she had recovered even before the methylprednisolone.
I feel while I can agree with their hypothesis, it's still possible that her supposed intestinal vasculitis was recovering slowly and yesterday's iv methylprednisolone may have helped. Again not sure how to resolve this uncertainty except to await the macroscopic colonoscopic findings and microscopic histopathology of the intestine to check what was really going on there by sending her to NIMs and hoping for the best.
@PPM9 let's send her to NIMs on Friday👇
[11/02, 15:05] NIMS Gastro Kims UG PG: This week my Opd is on Wednesday and Friday sir.
And for next two weeks my Opd is on Tuesday , Thursday and Saturday. They can come on any of these days when she is stable .
[11/02, 15:46]: Our PGs will text you to coordinate.
13-02-2025
PPM 9 - Subjectively -patient feels better compared to yesterday
But yesterday after food intake - had abdominal pain which subsided with buscopan.
No vomitings
Passed stools yesterday afternoon.
Aki in resolving trends
Urea - 110---92
Creat -2.3 ---1.4
I/o - 2900ml/650ml
For the first time yesterday night bp-150/90mm hg
And since then bp recordings -are 160/100mmhg
PPM 1 - Thanks
3 doses of methyl prednisolone over?
PPM 9 - Today is the last dose sir.
PPM 1 - 👍What about her 24 hour protein and creatinine?
PPM 9 - 
PPM 1 - Even the Lupus patient in the opposite bed had the same value?!!
PPM 9 - Yes sir almost similar.
PPM 1 - If this is true then this is the closest she has come to remission!
Now how much of that was due to her azathioprine (for which pancreatitis was one of the current differentials for her abdominal pain) and how much is due to one dose of methyl prednisolone is a big head scratcher! @Aditya?
PPM 16 - 
PPM 1 - So one thing is clear after reading this that when we think of intestinal vasculitis in Lupus it needs to be before the vessels enter the intestine. In that case its difficult to explain her ultrasound findings of bowel thickening.
PPM 1 - Please share the URL to the article.
PPM 16 - Many URL''s are there sir.. I searched for pathology of intestinal vasculitis in Lupus...
Also to prove Lupus intestinal vasculitis truly one may actually require laparoscopic biopsy of the affected vessels before they enter the intestine in the mesentery which in this particular patient will be very difficult to say the least.
However a colonoscopy to chase the USG bowel thickening is still worthwhile and if there's really a lesion there then a biopsy could tell a lot provided we a good coordination between endoscopist and pathologist.
Always share the URL to the full text of whatever screenshot you share and that's a general dictum as it helps the audience to at least check out the full text of the fragment shared in screenshot.
PPM 16 - 👍
Sir patient and attender are not affordable for ambulance all to KHL and colonoscopy charges too....
PPM 1 - Yes we were planning for NIMs @PPM9 were you able to find out from Srujan?
I talked to the father who wants to go to NIMs next week on Tuesday, Thursday or Saturday.
@PPM9 can you also get a rough estimate of the potential costs from Srujan.
He said that he will be available on Tuesday Thursday and Saturday
Since they will be discharged tomorrow
I think they can go on Tuesday sir to have an appointment for the later date
And colonoscopy would cost around 2.5k
With biopsy -rs.700 sir
Approx 3.4-4k would be an estimate sir.
PPM 1 - 👍
Please let her father know.
Can discharge her on Saturday.
PPM 9 - 👍
14-02-2025
PPM 1 - @PPM16 as a cyclic iv pulse cyclophosphamide is being planned for her under your guidance, it would be great if you can share any good RCT that shows efficacy of that regime vs other care
@PPM3 would be nice if you too could share.
Her BP spikes are an effect of iv methyl prednisolone or lupus nephritis?
PPM 16 - I'm unavailable today for discussion sir...
PPM 1 - 👍
PPM 17 - The abdomen is distended now sir visually
Yesterday the abdominal girth is 69 cms
Today eve it is 73 cms sir
She did not pass stools today.
PPM 1 - Thanks.
Let's hope we get her colonoscopy quickly before she again goes into another obstruction.
15-02-2025
PPM 16 - Our patient is having loose stools due to laxative sir, she is not feeling well, so instructed our
PG's to postpone plan for discharge and counseled the attenders too about the same sir..
Asked to shift patient to ward sir...
Goal is make her fit for colonoscopy guided biopsy on Tuesday.. @PPM1 sir.
EMR SUMMARY
Age/Gender : 22 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 09/02/2025 06:41 AM
Name of Treating Faculty
DR RAMJI (AP) DR HARIKA PGY2
DR TUSHARA PGY1
Diagnosis
?SLE WITH RECURRENT INTESTINAL OBSTRUCTION WITH DIFFERENTIALS:-
-SLE WITH ?MESENTERIC VASCULITIS ?IBD
-DRUG INDUCED GASTRITIS, ?PANCREATITIS
-K/C/O SLE WITH LUPUS NEPHRITIS ON IMMUNOSUPRESSION(LOW DOSE PREDNISOLONE AND AZATHIOPRINE 50MG OD)
INFECTIVE COLITIS SINCE 1 MONTH, RIGHT SIDED HYDROPNEUMOTHORAX (SEE PREVIOUS DISCHARGE)
S/P ICD PLACEMENT AND REMOVAL 1 YEAR BACK
-K/C/O HTN SINCE 2 MONTHS ACUTE KIDNEY INJURY (RENAL)
Case History and Clinical Findings
C/O PAIN ABDOMEN IN UMBILICAL REGION AND EPIGASTRIC REGION SINCE 12 HOURS HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 12 HOURS AGO AFTER WHICH PATIENT DEVELOPED PAIN ABDOMEN IN EPIGASTRIC REGION AND UMBILICAL REGION WHICH WAS
INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, NON RADIATING, NO AGGRAVATING
FACTORS, RELIEVED IN PRONE POSITION ASSOCIATED WITH VOMITINGS (6 EPISODES), NON-PROJECTILE, NON-MUCOID, NON-BILIOUS, FOOD AS CONTENT.
NO C/O SOB, PALPITATIONS, DECREASED URINE OUTPUT, FACIAL PUFFINESS, LOOSE STOOLS, CONSTIPATION, PEDAL EDEMA
NO C/O FEVER, COUGH, COLD.
H/O RIGHT SIDED HYDROPNEUMOTHORAX S/P ICD PLACEMENT AND REMOVAL 1 YEAR BACK
PAST HISTORY:-
K/C/O SLE WITH LUPUS NEPHRITIS SINCE 3 YEARS K/C/O HTN SINCE 10 DAYS
N/K/C/O DM, TB, THYROID, CVA, CAD, EPILEPSY GENERAL EXAMINATION:-
PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA BP: 120/80MMHG
PR: 86BPM RR: 18CPM
SPO2: 97% AT RA APPETITE NORMAL BOWELS REGULAR MICTURITION NORMAL NO ALLERGIES
NO ADDICTIONS SYSTEMIC EXAMINATION:-
CVS: S1,S2 +, NO MURMURS RS: BAE+, NVBS HEARD
P/A: TENDERNESS IN UMBILICAL REGION CNS: NFND
SURGERY REFERRAL DONE ON 10/2/2025:- PER ABDOMEN: INSPECTION:-
NO VISIBLY ENGORGED VEINS, PULSATIONS OR PERISTALSIS NO VISIBLE MASSES OR SWELLING PER ABDOMEN
NO VISIBLE SCARS OR SINUSES PALPATION: ABDOMEN IS SOFT
TENDERNESS + IN RIGHT LUMBAR, RIGHT ILIAC AND RIGHT UMBILICAL REGIONS NO PALPABLE MASSES/SWELLINGS PER ABDOMEN
NO GUARDING/RIGIDITY
NO HEPATOSPLENOMEGALY/ORGANOMEGALY PERCUSSION: NORMAL LIVER DULLNESS ELICITED
RIGHT OF THE ABDOMEN IS RESONANT AUSCULTATION: BS+
USG ABDOMEN AND PELVIS: CIRCUMFERENTIAL LONG SEGMENTS BOWEL WALL THICKENING NOTED
SMALL BOWEL MEASURING 5MM OF THICKNESS LARGE BOWEL MEASURING 9-10MM OF THICKNESS LIKELY INFECTIVE INFLAMMATORY ETIOLOGY
MILD PERIHEPATIC AND INTERBOWEL FREE FLUID NOTED IN PELVIS ADVICE: PROCTOGLYSIS ENEMA/STAT
CST BY PRIMARY PHYSICIAN REVIEW SOS
Investigation
LIVER FUNCTION TEST (LFT) 09-02-2025 07:11:AMTotal Bilurubin 1.02 mg/dl 1-0 mg/dlDirect Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 16 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0
IU/LALKALINE PHOSPHATASE 126 IU/L 98-42 IU/LTOTAL PROTEINS 5.9 gm/dl 8.3-6.4
gm/dlALBUMIN 3.06 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.08
HEMOGRAM 9/2/2025:-
HAEMOGLOBIN 9.4 gm/dl 12.0 - 15.0 ColorimetricTOTAL COUNT 12,700 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 88 % 40 - 80 Light MicroscopyLYMPHOCYTES 10 % 20 - 40 Light
MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 01 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 27.6 vol % 36 - 46 CalculationM C V 81.9 fl
83 - 101 CalculationM C H 27.9 pg 27 - 32 CalculationM C H C 34.1 % 31.5 - 34.5 CalculationRDW-
CV 16.0 % 11.6 - 14.0 HistogramRDW-SD 48.4 fl 39.0-46.0 HistogramRBC COUNT 3.37
millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 4.5 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC Increased in count with Neutrophilia Light MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia with Neutrophilic Leukocytosis
RBS 90 mg/dl. 100 - 160 GOD - POD
Anti HCV Antibodies - RAPID 09-02-2025 07:11:AM Non ReactiveHBsAg-RAPID 09-02-2025 07:11:AM Negative
HIV NEGATIVE
BLOOD UREA 09-02-2025 07:11:AM 48 mg/dl 42-12 mg/dl
SERUM CREATININE 09-02-2025 07:11:AM 1.1 mg/dl 1.1-0.6 mg/dl
SPOT URINE PROTEIN 63 mg/dl.SPOTURINE CREATININE 79.7 mg/dl.RATIO 0.79
SERUM ELECTROLYTES (Na, K, C l) 09-02-2025 07:11:AMSODIUM 140 mmol/L 145-136
mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L
T3, T4, TSH 10-02-2025 08:03:AMT3 0.54 ng/ml 1.87-0.87 ng/mlT4 8.81 micro g/dl 12.23-6.32 micro
g/dlTSH 5.60 micro Iu/ml 5.36-0.34 micro Iu/ml
BLOOD UREA 10-02-2025 12:29:PM 87 mg/dl 42-12 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 10-02-2025 12:29:PMSODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/L
SERUM CREATININE 10-02-2025 12:29:PM 2.7 mg/dl 1.1-0.6 mg/dl
LIPID PROFILE:-Total Cholesterol 279 mg/dlTriglycerides 295 mg/dl 0 - 150 GPO-POD With
ESPASHDL Cholesterol 72 mg/dl 40 - 65 Direct EnzymaticLDL Cholesterol 122 mg/dl. 0 - 100 Direct EnzymaticVLDL * 59 mg/dl 12-40 mg/dl Direct Enzymatic
E S R 70 mm/ 1 st hour 5 - 20 Westergren
SERUM LIPASE 24.0 IU/L 13 - 60 Colorimetric
RFT 11-02-2025 04:13:AMUREA 113 mg/dl 42-12 mg/dlCREATININE 2.9 mg/dl 1.1-0.6 mg/dlURIC
ACID 8.1 mmol/L 6-2.6 mmol/LCALCIUM 9.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.4 mg/dl 4.5-2.5
mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
102 mmol/L 98-107 mmol/L
24 HOURS URINE PROTEIN 211 mg/day. <150 mg/day24 HOURS URINE CREATININE 0.8 g/day
1-3 gm /dayRATIO 0.26URINE VOLUME 500 ml
Blood Urea 12-02-2025: 110 mg/dl 12 - 42 Urease-GLDH
Serum Creatinine 2.3 mg/dl 0.6 - 1.1 Modified Jaffe's
SODIUM 135 mmol/L 136 - 145 Ion Selective ElectrodePOTASSIUM 4.4 mmol/L 3.5 - 5.1 Ion
Selective ElectrodeCHLORIDE 101 mmol/L 98 - 107 Ion Selective ElectrodeCALCIUM IONIZED 1.18 mmol/L Cord Blood : 1.30 - 1.602Hrs : 1.21 - 1.4624Hrs : 1.10 - 1.363Days : 1.15 - 1.425Days : 1.22 -
1.48Adults : 1.16 - 1.32 Ion Selective Electrode
COMPLETE URINE EXAMINATION 12-02-2025:-
COLOUR Pale yellow Pale Yellow Physical ExaminationAPPEARANCE Clear Clear Physical ExaminationREACTION Acidic 5.0-9.0 Reagent StripSP.GRAVITY 1.010 1.001-1.035 Reagent StripALBUMIN ++ Negative Reagent StripSUGAR Nil Negative Reagent StripBILE SALTS Nil Negative Reagent StripBILE PIGMENTS Nil Negative Reagent StripPUS CELLS 3-4 0-5/HPF Light MicroscopyEPITHELIAL CELLS 2-3 0-5/HPF Light MicroscopyRED BLOOD CELLS Nil 0-2/HPF Light MicroscopyCRYSTALS Nil Nil Light MicroscopyCASTS Nil Nil Light MicroscopyAMORPHOUS DEPOSITS Absent Nil Light MicroscopyOTHERS Nil Nil Light Microscopy
HEMOGRAM 13-02-2025:-
HAEMOGLOBIN 7.0 gm/dl 12.0 - 15.0 ColorimetricTOTAL COUNT 16,600 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 92 % 40 - 80 Light MicroscopyLYMPHOCYTES 05 % 20 - 40 Light
MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 02 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 20.6 vol % 36 - 46 CalculationM C V 84.8 fl
83 - 101 CalculationM C H 28.8 pg 27 - 32 CalculationM C H C 34.0 % 31.5 - 34.5 CalculationRDW-
CV 16.5 % 11.6 - 14.0 HistogramRDW-SD 51.0 fl 39.0-46.0 HistogramRBC COUNT 2.43
millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 2.5 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC Increased on smear Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemia with neutrophilic leucocytosis
RFT 13-02-2025:-
UREA 92 mg/dl 12 - 42 Urease-GLDHCREATININE 1.4 mg/dl 0.6 - 1.1 Modified Jaffe'sURIC ACID
7.5 mmol/L 2.6 - 6 Uricase-POD With DHBSCALCIUM 8.3 mg/dl 8.6 - 10.2 Arsenazo
IIIPHOSPHOROUS 2.8 mg/dl 2.5 - 4.5 Direct UV without reductionSODIUM 135 mmol/L 136 - 145
Ion Selective ElectrodePOTASSIUM 4.0 mmol/L. 3.5 - 5.1 Ion Selective ElectrodeCHLORIDE 104 mmol/L 98 - 107 Ion Selective Electrode
RFT 14-2-2025:-
UREA 79 mg/dl 12 - 42 Urease-GLDHCREATININE 1.2 mg/dl 0.6 - 1.1 Modified Jaffe'sURIC ACID
5.7 mmol/L 2.6 - 6 Uricase-POD With DHBSCALCIUM 7.8 mg/dl 8.6 - 10.2 Arsenazo
IIIPHOSPHOROUS 2.4 mg/dl 2.5 - 4.5 Direct UV without reductionSODIUM 136 mmol/L 136 - 145
Ion Selective ElectrodePOTASSIUM 4.3 mmol/L. 3.5 - 5.1 Ion Selective ElectrodeCHLORIDE 105 mmol/L 98 - 107 Ion Selective Electrode
HEMOGRAM 15-02-2025:-
HAEMOGLOBIN 7.2 gm/dl 12.0 - 15.0 ColorimetricTOTAL COUNT 5,000 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 65 % 40 - 80 Light MicroscopyLYMPHOCYTES 22 % 20 - 40 Light
MicroscopyEOSINOPHILS 03 % 01 - 06 Light MicroscopyMONOCYTES 10 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 21.0 vol % 36 - 46 CalculationM C V 83.7 fl
83 - 101 CalculationM C H 28.7 pg 27 - 32 CalculationM C H C 34.3 % 31.5 - 34.5 CalculationRDW-
CV 16.2 % 11.6 - 14.0 HistogramRDW-SD 49.7 fl 39.0-46.0 HistogramRBC COUNT 2.51
millions/cumm 3.8 - 4.8 ImpedencePLATELET COUNT 2.67 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic Anemia
RFT 15-02-2025:-
UREA 56 mg/dl 12 - 42 Urease-GLDHCREATININE 1.0 mg/dl 0.6 - 1.1 Modified Jaffe'sURIC ACID
4.4 mmol/L 2.6 - 6 Uricase-POD With DHBSCALCIUM 7.4 mg/dl 8.6 - 10.2 Arsenazo
IIIPHOSPHOROUS 2.0 mg/dl 2.5 - 4.5 Direct UV without reductionSODIUM 135 mmol/L 136 - 145
Ion Selective ElectrodePOTASSIUM 3.8 mmol/L. 3.5 - 5.1 Ion Selective ElectrodeCHLORIDE 104 mmol/L 98 - 107 Ion Selective Electrode
USG ABDOMEN AND PELVIS DONE ON 9/2/25:- RIGHT KIDNEY 9.4 X 4.2CM, N S/E, CMD+, PCS N LEFT KIDNEY 9.4 X 4.5CM, N S/E, CMD+, PCS N UTERUS SIZE 6.9 X 4.2CM
ENDOMETRIAL THICKNESS 6-7MM FINDINGS/IMPRESSION:-
-CIRCUMFERENTIAL LONG SEGMENT BOWEL WALL THICKENING NOTED, SMALL BOWEL WALL MEASURING 5MM AND LARGE BOWEL WALL MEASURING 9-10MM OF THICKNESS, LIKELY INFECTIVE/INFLAMMATORY ETIOLOGY.
-MILD PERIHEPATIC AND INTERBOWEL FREE FLUID NOTED IN PELVIS.
Treatment Given(Enter only Generic Name)
NBM TILL FURTHER ORDERS
IV FLUIDS NS '100ML/HR; 10%DEXTROSE WITH 1 AMP OPTINEURON INJ TRAMADOL 1AMP IN 100ML NS IV/SOS
INJ ZOFER 8MG IV/TID INJ BUSCOPAN IV/BD
INJ PAN 40MG IV/OD 1-0-0
SYP MUCAINE GEL 10MG PO/TID 1-1-1
1 ORS SACHET IN 250MLO OF WATER THRICE DAILY MONITOR VITALS AND INFORM SOS
Advice at Discharge
TO MEET DR SRUJAN GASTRO, NIMS FOR COLONOSCOPY AND BIOPSY FO COLONIC LESION WITH USG SUGGESTED BY A SONOLOGIST.
SYP MUCAINE GEL 10MG PO/TID 1-1-1
1 ORS SACHET IN 250MLO OF WATER THRICE DAILY T.WYSOLONE 10MG OD TO CONTINUE T.AZATHIOPRINE 50MG OD TO CONTINUE
Follow Up
REVIEW TO GM OPD AFTER 1 MONTH
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:15/2/2025 Ward: FMW Unit: IV
19-02-2025
Caretaker - Good evening sir, can you please prescribe the tablets for the patient.
PPM 1 - @PPM12 @PPM9 they were supposed to visit NIMS yesterday?
Please share the tablets your patient is currently taking. Her colonoscopy is planned on Friday.
Please ask her to continue the tablets she was previously taking till we get her colonoscopy report.
@PPM2 proctologist texted. He'll also try to get her colonoscopy bill waived. They may have to pay for the pathology bill. I guess that would be great.
PPM 9 - Yes sir they visited and they are scheduled on Friday for colonoscopy
They have doubt regards what medications to continue and have cleared them sir.
PPM 1 - 👍
21-02-2025
PPM 1 - Update:
The colonoscopy mucosa appeared normal?
Could it have been an intestinal vasculitic flare up that gave rise to her intestinal obstruction symptoms then?
PPM 9 - Vasculitic flare up only supports it I think so sir.
PPM 1 - Yes! @PPM16
[21/02, 16:18] NIMS Gastro KIMS UG PG: The mucosa upto the terminal ileum was normal sir. Vasculitic flare is one possibility and the other may be small bowel strictures which cause intermittent obstruction too. As she is asymptomatic now, it would be better to get a cect enterography the next time she gets any features if obstruction. We did take biopsy just in case.
PPM 16 - Acute on Chronic vasculitis with strictures causing pseudo obstruction sir...
PPM 1 - 👍
24-02-2025
PPM 6 - Patient admitted today morning with complaints of vomitings since 4 am 4-5 episodes
1 st episode was some of the food contents and watery.
Next episodes patient complains of hematemesis - dark colored
No complaints of pain abdomen, constipation, fever
Vitals on presentation
PR: 92/min
BP: 110/70 mmHg
Spo2: 95 on RA
RR:22 cpm
P/A: soft, non-tender
PPM 16 - Have they taken any photo of haematemesis??
How sure you are it's haematemesis??
PPM 1 - Any maintenance prednisolone she was on at discharge?
PPM 6 - Yes sir
She is on prednisolone 10 mg po od, tab. Azathioprine 50 mg po od.
PPM 1 - I checked in the afternoon. Although we had written 10 they were taking 5 but I guess that's okay and may not be responsible for hypoadrenalism causing her current symptoms.
Drug induced gastritis is the other possibility for which we shall get her upper GI endoscopy tomorrow.
25-02-2025
PPM 1 - Update
USG abd done on 24th Feb already sir.
PPM 1 - 👍
BP charting since 4:00PM revealed higher spikes 140/100 to 150/100 and night 7:30 PM took Telma 40 and hourly BP monitoring slightly relented although today it's again higher before her planned upper GI endoscopy. @PPM6 we'll also need to review her 24 hour urinary protein and creatinine which for the first time had shown near remission of her lupus nephritis during last admission.
PPM 1 - upper GI endoscopy done today.
26-02-2025
PPM 1 - Current problem:
Persistent vomiting immediately after food
Invite inputs @PPM@, @PPM3, @PPM16.
PPM 16 - I shall give my inputs tomorrow sir after talking to the patient..
PPM 1 - 👍
PPM 3 - Given her complaints :
22F immunosuppressive with acute to sub acute abdominal pain and vomitings with Flare up of Lupus nephritis. With background of endocarditis
*assuming Normal UGIE attached above
Localisation -
GI -
1. Mesentric ischemia / intestinal angina
2. Lupus enteritis / Vasculitis ( sub acute ) - associated with flare up of LN
2. IBD
3. ischemic colitis ( ?mesentric vessels occlusion again )
? External compression of bowel or blood vessel
Renal - azotemia / ?middle molecules triggering CTZ
CNS- raised ICP ( less likely )
@PPM6 did we do her CT angio..? Or CECT abd..?
PPM 7 - Cect abd or CT angio was not done sir
PPM 2 - How would they help?
Why not drug induced? Vomiting immediately after eating?
PPM 3 - Yes sir possible. She is been on AZA which could cause pancreatitis too.
PPM 2 - Relevant bits please.
PPM 2 - Yeah. So maybe Lipase with a USG should suffice for now?
PPM 7 - One of our faculty was thinking it could be cyclic vomiting syndrome as a differential sir
PPM 2 - Isn't that a diagnosis of exclusion and is usually not sinister as seen here?
PPM 3 - Rather colonoscopy would be better.
Look for any signs of bowel inflammation or ischemia or an ulcers and take a bit for histopathology.
PPM 2 - Vomiting immediately after food intake would localise the problem much higher wouldn't it? Which means the problem is involving the digestive machinery - esophagus, stomach, hepato-pancreatico-biliary organs?
PPM 7 - 
Upper GI endoscopy in our hospital. Biopsy report will be updated tomorrow sir.
It was done in NIMS sir
PPM 3 - Correct sir here macroscopic visualisation of mucosa seems normal.
🏏
PPM 2 - I wish I had WhatsApp AI but can you please ask what is the incidence of vomiting in patients taking Azathioprine?
PPM 3 - @Meta AI incidence of vomitings in patients in chronic azathioprine
Meta AI - Azathioprine is an immunosuppressive medication commonly used to treat autoimmune diseases, prevent organ rejection in transplant patients, and manage certain inflammatory conditions.
Regarding the incidence of vomiting in patients taking chronic azathioprine, here are some findings:
- A study published in the Journal of Clinical Pharmacology found that gastrointestinal symptoms, including nausea and vomiting, occurred in approximately 12% of patients taking azathioprine (1).
- Another study published in the British Journal of Clinical Pharmacology reported that vomiting was experienced by around 5% of patients receiving azathioprine (2).
- A review of azathioprine's safety profile published in the journal Expert Opinion on Drug Safety noted that gastrointestinal adverse effects, including vomiting, are relatively common, affecting up to 20% of patients (3).
Please note that the incidence of vomiting can vary depending on factors such as:
- Dosage: Higher doses may increase the risk of gastrointestinal side effects.
- Individual tolerance: Some patients may be more susceptible to azathioprine's side effects.
- Concomitant medications: Taking other medications that can cause gastrointestinal upset may increase the risk of vomiting.
If you're experiencing persistent or severe vomiting while taking azathioprine, it's essential to consult your healthcare provider for proper evaluation and guidance.
References:
1. Journal of Clinical Pharmacology, "Azathioprine-induced gastrointestinal symptoms: a review of the literature" (2018)
2. British Journal of Clinical Pharmacology, "Adverse effects of azathioprine in patients with inflammatory bowel disease" (2015)
3. Expert Opinion on Drug Safety, "Azathioprine: a review of its safety profile" (2019)
I hope this helps! If you have further questions or concerns, feel free to ask.
PPM 2 - Please ask absolute numbers and duration of Azathioprine in study 1.
PPM 7 - @Meta AI absolute numbers and duration of Azathioprine in study 1.
Meta AI -
In Study 1, the absolute numbers and duration of Azathioprine were as follows:
- Number of patients: 40 children with inflammatory bowel disease (IBD) ¹
- Duration of Azathioprine treatment: The study doesn't explicitly state the duration, but it mentions that thiopurines can take up to 14 weeks to be fully effective ¹
- Azathioprine dose: The mean azathioprine dose was 1.3±0.4 mg/kg ¹
- Thiopurine metabolite measurement timing: Blood tests were performed 6 weeks after the initiation of therapy ¹
Meta AI
PPM 3 - @PPM2 @PPM7
Incidence of Vomiting in Chronic Azathioprine Use: A Comprehensive Analysis of Large-Scale Medical Studies
Azathioprine, a widely used immunosuppressive agent, has demonstrated clinical efficacy across various autoimmune and inflammatory conditions. However, its therapeutic benefits are often accompanied by gastrointestinal adverse effects, with vomiting representing a clinically significant concern. This report synthesizes data from multiple large-scale studies to quantify the incidence of vomiting during chronic azathioprine therapy, providing granular insights into population-specific risks, dose dependencies, and management strategies.
---
## Epidemiological Overview of Azathioprine-Associated Vomiting
The incidence of vomiting during azathioprine therapy varies substantially across patient populations and treatment protocols. A landmark study involving *622 inflammatory bowel disease (IBD) patients* revealed that *68 patients (10.9%)* discontinued treatment due to nausea and vomiting, with symptoms typically emerging within a mean of *106 days* after initiation[6]. Notably, this cohort received a mean dose of *1.77 mg/kg/day, though no direct correlation between dose intensity and emetic frequency was observed[6]. These findings align with a Korean pediatric IBD study where **27 of 174 patients (15.5%)* experienced vomiting at a mean dose of *1.38 mg/kg/day, with **10 patients (5.7% of total cohort)* requiring permanent discontinuation[3][5].
---
## Dose-Response Relationships and Temporal Patterns
Contrary to conventional pharmacokinetic expectations, vomiting incidence does not exhibit strong dose dependency. In the Korean pediatric cohort, vomiting occurred across a broad dose range (*1.38 ± 0.46 mg/kg/day), with symptom onset delayed until a mean of **10.4 months* into therapy[3]. This contrasts with adult populations where emetic episodes frequently manifest earlier, suggesting age-related differences in drug tolerance. A paradoxical observation emerged from a 14-patient gastritis study, where only *1 patient (7.1%)* developed dose-limiting nausea/vomiting despite prolonged azathioprine exposure (>2.5 months)[2], highlighting condition-specific variability in adverse effect profiles.
---
## Population-Specific Risk Stratification
### Pediatric vs. Adult Populations
Pediatric patients demonstrate heightened vulnerability, with *15.5% vomiting incidence* in Korean children[3] versus *10.9%* in mixed-age IBD cohorts[6]. This disparity may reflect developmental differences in thiopurine methyltransferase (TPMT) activity or enterohepatic recirculation patterns. Notably, pediatric data showed *37% of vomiting cases* required dose reduction, while adults predominantly required complete cessation[3][6].
### Disease-State Modifiers
IBD patients exhibit higher emetic rates (*10.9-15.5%[3][6]) compared to transplant recipients (<1%[4]). This discrepancy likely stems from baseline gastrointestinal inflammation in IBD exacerbating drug-induced mucosal irritation. A critical finding from the 622-patient IBD study revealed **64% remission rates* in Crohn's disease patients persisting beyond six months of therapy despite vomiting incidence[6], underscoring the risk-benefit calculus in chronic management.
---
## Management Algorithms and Clinical Outcomes
### Pharmacological Interventions
Proactive antiemetic use remains controversial due to potential drug interactions. The NHS guidelines recommend dietary modifications (e.g., administration with meals) as first-line management, reporting symptom resolution within one week for most patients[1]. Refractory cases often necessitate dose reduction, successful in *29.6% of pediatric patients*[3], though this risks subtherapeutic immunosuppression.
### Discontinuation Thresholds
Permanent cessation rates vary by indication:
- *5.7%* in pediatric IBD[3]
- *10.9%* in adult IBD[6]
- *7.1%* in chronic gastritis[2]
Notably, *17% of adult IBD patients* restarting azathioprine after initial intolerance achieved long-term tolerance through gradual dose escalation[6], suggesting protocolized rechallenge strategies may mitigate attrition.
---
## Mechanistic Considerations in Emetogenesis
The dual-phase vomiting pathophysiology involves:
1. *Direct mucosal irritation* via 6-thioguanine nucleotide accumulation in gut epithelium[4]
2. *Central chemoreceptor activation* through proinflammatory cytokine cross-talk (IL-6, TNF-α)[3]
Hepatic metabolism polymorphisms further modulate risk, with slow TPMT metabolizers showing *3.2-fold increased emetic propensity* in pharmacogenetic subanalyses[6]. These insights inform emerging genotype-guided dosing protocols aiming to balance efficacy and tolerability.
---
## Longitudinal Safety Data
The 622-patient cohort provided critical temporal insights:
- *42.3% of vomiting cases* occurred within 3 months
- *28.1%* manifested between 3-12 months
- *29.6%* emerged after >1 year of therapy[6]
This prolonged risk window contradicts traditional "early toxicity" paradigms, necessitating ongoing monitoring even in long-term users. Late-onset cases correlated with cumulative dose thresholds exceeding *200g*, suggesting mitochondrial toxicity mechanisms[4].
---
## Comparative Safety Profiles
While vomiting represents a predominant gastrointestinal effect, its incidence eclipses other azathioprine toxicities:
- *4.6% leukopenia*[6]
- *7.5% pancreatitis*[3]
- *2.9% hepatotoxicity*[3]
Notably, *68% of drug discontinuations* stem from vomiting/nausea compared to *4.6% for hematologic effects*[6], emphasizing its clinical impact on treatment adherence.
---
## Conclusion: Risk Mitigation in Clinical Practice
Synthesizing data from 796 patients across three continents, chronic azathioprine therapy carries a *11-15% vomiting risk, with absolute case numbers ranging from **68/622[6] to **27/174*[3] in large cohorts. Proactive genotype screening (TPMT, NUDT15), staggered dosing protocols, and early antiemetic support may reduce attrition. Future research should prioritize randomized trials of aprepitant and olanzapine as prophylactic agents in high-risk populations.
Sources
[1] Side effects of azathioprine - NHS https://www.nhs.uk/medicines/azathioprine/side-effects-of-azathioprine/
[2] The effect of azathioprine on gastric mucosal histology and acid ... https://pubmed.ncbi.nlm.nih.gov/4696531/
[3] Adverse Events Associated with Azathioprine Treatment in Korean ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3819691/
[4] Azathioprine Side Effects: Common, Severe, Long Term - Drugs.com https://www.drugs.com/sfx/azathioprine-side-effects.html
[5] [PDF] Adverse Events Associated with Azathioprine Treatment in Korean ... https://www.pghn.org/Synapse/Data/PDFData/1121PGHN/pghn-16-171.pdf
[6] The efficacy of azathioprine for the treatment of inflammatory bowel ... https://pmc.ncbi.nlm.nih.gov/articles/PMC1773162/
[7] Long -term safety and toxicity of azathioprine in patients with air ... https://ijdvl.com/long-term-safety-and-toxicity-of-azathioprine-in-patients-with-air-borne-contact-dermatitis/
[8] [PDF] Azathioprine (Imuran) https://www.cuh.hse.ie/media/pil/azathioprine-imuran-gp-sheet-2023.pdf
[9] Effect of azathioprine intolerance on outcomes of inflammatory ... https://pmc.ncbi.nlm.nih.gov/articles/PMC5369706/
[10] Hypersensitivity to azathioprine in a patient with Crohn's disease http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082017001000013
[11] Long‐term safety and effectiveness of azathioprine in the ... https://onlinelibrary.wiley.com/doi/full/10.1002/jgh3.12955
[12] azathioprine oral: Uses, Side Effects, Interactions, Pictures ... - WebMD https://www.webmd.com/drugs/2/drug-13771/azathioprine-oral/details
[13] Azathioprine (Imuran®) Drug Information Sheet https://www.hopkinsarthritis.org/patient-corner/drug-information/azathioprine-imuran/
[14] [PDF] 787fm.3 azathioprine for use in rheumatology, dermatology https://www.bucksformulary.nhs.uk/docs/Guideline_787FM.pdf
[15] Azathioprine (oral route) - Mayo Clinic https://www.mayoclinic.org/drugs-supplements/azathioprine-oral-route/description/drg-20067180
[16] Long-term Efficacy and Safety of Azathioprine in Ulcerative Colitis https://academic.oup.com/ecco-jcc/article/9/2/191/439760
[17] [PDF] updated azathioprine guidelines. - London - Whittington Hospital https://www.whittington.nhs.uk/document.ashx?id=6404
[18] Azathioprine (Imuran®) Uses and Side Effects https://www.chp.edu/our-services/transplant/liver/education/medications/azathioprine-imuran
[19] Weekly azathioprine pulse versus daily azathioprine in the treatment ... https://ijdvl.com/weekly-azathioprine-pulse-versus-daily-azathioprine-in-the-treatment-of-parthenium-dermatitis-a-non-inferiority-randomized-controlled-study/
[20] Azathioprine: Side Effects, Dosage, Uses, and More - Healthline https://www.healthline.com/health/drugs/azathioprine-oral-tablet
[21] Azathioprine - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK542190/
[22] Azathioprine: Side Effects & Treatment - Cleveland Clinic https://my.clevelandclinic.org/health/drugs/9407-azathioprine
[23] Azathioprine | Side-effects, uses, time to work - Versus Arthritis https://versusarthritis.org/about-arthritis/treatments/drugs/azathioprine/
[24] Toxicity of azathioprine: why and when? analysis of the prevalence ... https://www.scielo.br/j/ag/a/f9L5FC63GsTFFxvJsZ3TrrN/
[25] Real-World Study Finds Long-Term Azathioprine Treatment Safe ... https://www.managedhealthcareexecutive.com/view/real-world-study-finds-long-term-azathioprine-treatment-safe-effective-in-patients-with-ibd
[26] Long‐term safety and effectiveness of azathioprine in the ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10517446/
[27] Azathioprine in ulcerative colitis: Why, when, how and how long to ... https://analyticalsciencejournals.onlinelibrary.wiley.com/doi/10.1002/ddr.20481
[28] [PDF] Azathioprine for patients within adult services (non-transplant ... https://www.covwarkformulary.nhs.uk/docs/chapter01/SCA102-Azathioprine%20non%20transplant%20indications.pdf
PPM 2 - 👍
PPM 7 - According to the above study, azathioprine causes vomiting in 10-15% patients sir.
PPM 3 - Yes this could help too @PPM7
PPM 6 - Lipase done during previous admission was normal sir.
PPM 7 - She had similar complaints at that time too sir, Lipase was normal.
27-02-2025
PPM 2 - This pretty much nails it doesn't it.
PPM 3 - 👍
PPM 1 - Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating
However having said that I guess we should stop azathioprine for now
Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission.
PPM 9 -
PPM 1 - Creatinine not done! The sample volume may have been inadequate!
Let's repeat the urine for 24 hour collection tomorrow!
[27/02, 14:35] pg: Can we plan renal biospy for her sir?!
[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.
Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today
So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!
Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!
Why is the volume oliguric? Can we have the 24 hour intake output since few days that she got admitted?
PPM 9 - Yesterday -2000/400ml
PPM 1 - Day before?
Today's?
PPM 9 - Sir till evening there was no output
28-02-2025
PPM 17 - 1050/200 ml on 26 th sir
Today -1100/250 ml sir
PPM 1 - You mean yesterday's 24 hour urine output was 250 ml?
Last serum creatinine?
She is dehydrated
And after iv fluids- urine output was 250ml sir
Slightly better compared to yesterday
2 episodes of vomitings
Pain abdomen+
Tenderness in the epigastric region.
No fever spikes
Has passed stools yesterday
S.creat -1.0
PPM 1 - 👍
Yes let's monitor the urine output hourly and replenish her volume hourly as per our hourly evaluation of her ivc mobility.
@PPM3 you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @PPM18 also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.
We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @PPM5 just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet.
PPM 3 - Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.
Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir.
PPM 1 - 👍
01-03-2025
PPM 16 - 
As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks!
PPM 16 - In summary, the cumulative exposure to CYC that
results in ovarian failure varies by age. To avoid
amenorrhea, female patients < 20 years old should
likely receive < 15 to 20 g of total exposure, patients
aged 20 to 30 should receive < 15 g of total exposure
and those > 30 should likely receive < 10 g of total
exposure. We did not make a recommendation for
maximum exposure to prevent infertility in patients
> 40 as this group already has a low baseline fertility
rate, worsened by disease activity. In males, the
maximum CYC exposure for patients who still wish to
conceive is lower at approximately 10 g.
We are just calculating the cost of tablets sir. Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..
PPM 1 - 👍
Agree! Well said 👏
So the harms appear to be worth a try!
Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil
[01/03, 08.31] PPM 16 - Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...
[01/03, 09.10] PPM 16 - https://bmjopen.bmj.com/content/2/5/e001471
So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based...
In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....
[01/03, 08.34] PPM 16 - We are repeating lipase today sir...
Specificity of lipase is roughly 99 %...
We have to await for lipase results to say it's pancreatitis...
[01/03,08.37] PPM 16 - One thing is very clear sir, she is having disease activity, and requires immunosuppression immediately, then planned for renal biopsy for definitive decision making.
[01/03,08.48] PPM 1 - Specificity may not be as important as sensitivity here in this case who already had demonstrated normal lipase during her previous acute attack during her previous admission!
Sensitivity is more important because if it's negative we will still not be able to rule it out as it's known to have sensitivity varying from 64-100%
Here's a paper citing the same including the fact that even specificity isn't 100% for pancreatitis as IBD can often have high lipase!
[01/03,08.51] PPM 1 -Agree that she has disease activity and we have been able to suppress it using drugs in the past unfortunately that we are having to discontinue because of cumulative side effects.
In view of no definitive data toward cyclophosphamide which will also need to be discontinued after a few months, i would prefer starting mycofenolate mofetil albeit expensive
However if there is good evidence of a cyclophosphamide pulse showing complete remission without recurrence it could be worth considering. However we need to see the evidence for it. @PPM3 would you like to try perplexity again for this?
PPM 3 - 👍
[01/03,09.07] PPM 16 - Diagnostic accuracy of serum lipase and amylase as biomarkers for
acute pancreatitis
[01/03,09.09] PPM 16 - https://www.msjonline.org/index.php/ijrms/article/download/4772/3915/19147
[01/03, 09.13] PPM 16 - I'm thinking that patient has less probability of pancreatitis sir..
Both sensitivity and specificity are high for lipase..
Helps to both rule out, as well as rule in with almost certainty....
[01/03, 09.18] PPM 1 - Sensitivity can vary from 64-100%
Negative doesn't rule out.
[01/03, 09.19] PPM 16 - 
What was her previous amylase lipase during the last admission managed by @PPM6 where our first clinical impression was pancreatitis but we kind of gave it up once the enzymes didn't support that hypothesis.
[01/03,09.19] PPM 1 - What is our alternate diagnosis for her symptoms?
[01/03, 09.20] PPM 16 - Though not meeting the cutoff, I'm convinced that patient is having pancreatitis sir...
Withholding azathioprine is justified sir...
PPM 1 - 👍
[01/03, 09.21] PPM 16 - Considering her symptoms examination findings and elevation in enzymes...
[01/03, 09.25] PPM 1 - 👍
[01/03, 09.36] PPM 6 - Previous admission lipase was 24 IU/L sir.
[01/03, 09.44] PPM 1 - 👍
An important learning point worth exploring further here in a thesis project here would be the variability of enzymatic activity in pancreatitis and how a longitudinal follow up is necessary for diagnosis rather than just a few random values? @PPM3 @PPM2
[01/03, 09.45] PPM 2 - Is this usually 2x or 3x? I remember 3x.
[01/03, 09.45] PPM 16 - 3x sir
[01/01, 09.46] PPM 2 - So if 24 is her usual count and 110 is nearly 5x, does this PaJR (highly individual centric and highly specific) number actually diagnose a pancreatitis?
PPM 1 - 👍
[01/03, 09.46] PPM 2 - Please can you give us the dates of the 24 and this 110?
@PPM6
Thanks.
[01/03, 09.49] PPM 6 - On 10th Feb sir.
Hence it's possible that the enzyme evaluation needs to be streamlined globally and not just for this particular patient and hence the need for a thesis.
[01/03, 10.01] PPM 1 - @PPM19 thesis was the first to point us in this direction of a possibility of finding the window of enzyme rise correlating with pancreatic inflammation.
[01/03, 10.30] PPM 2 - Thanks. And when was 110?
[01/03, 10.30] PPM 2 - I'm sure there are global thesis on this issue.
[01/03, 10.31] PPM 2 - At a deeper level, it does hark back to clinical suspicion trumping all else?
[01/03, 10.32] PPM 16 - Today sir.
[01/03, 10.40] PPM 3 -
Efficacy of Cyclophosphamide Pulse Therapy in Lupus Nephritis: Comparative Analysis Against Methylprednisolone and Placebo
Cyclophosphamide pulse therapy remains a cornerstone in the management of lupus nephritis (LN), demonstrating superior efficacy over methylprednisolone monotherapy and placebo in preserving renal function, inducing remission, and reducing relapse rates. High-quality evidence from randomized trials and meta-analyses supports its role as a first-line induction therapy, particularly in proliferative LN classes III/IV. This report synthesizes data on dosing strategies, combination regimens, safety profiles, and long-term outcomes to delineate cyclophosphamide’s therapeutic advantages.
Cyclophosphamide-Methylprednisolone Synergy in Induction Therapy
Superior Remission Rates with Combination Regimens
Combining cyclophosphamide pulses with intravenous methylprednisolone significantly enhances remission rates compared to methylprednisolone alone. In a 38-month observational study of 39 proliferative LN patients, 82.05% achieved remission (51.28% complete, 30.77% partial) following induction with methylprednisolone and monthly cyclophosphamide pulses (target cumulative dose: 200 mg/kg). Early initiation (<6 months from diagnosis) correlated with higher remission likelihood (P=0.04), underscoring the time-sensitive nature of aggressive immunosuppression[1]. Mechanistically, cyclophosphamide suppresses lymphocyte proliferation, complementing methylprednisolone’s anti-inflammatory effects to reduce glomerular immune complex deposition.
Head-to-Head Comparisons with Methylprednisolone Monotherapy
Methylprednisolone alone demonstrates inadequate disease control in severe LN. In refractory cases, a phase II trial comparing rituximab/cyclophosphamide (RC) versus rituximab/cyclophosphamide/belimumab (RCB) found no significant difference in renal response rates (RCB: 52%, RC: 41%; P=0.452), highlighting cyclophosphamide’s irreplaceable role even in biologic combination regimens[2]. Notably, 73% of treatment failures stemmed from lack of improvement or worsening LN, emphasizing the necessity of cyclophosphamide’s cytotoxic action in halting autoimmune renal damage.
Pulse vs. Continuous Cyclophosphamide Regimens
Meta-Analysis of Dosing Strategies
A meta-analysis of 12 randomized trials (994 patients) revealed distinct advantages of short-interval, lower-dose intravenous cyclophosphamide (e.g., EuroLupus protocol: 500 mg fortnightly for 3 months) over traditional high-dose regimens:
- *24-hour proteinuria reduction: Mean difference -0.45 g/day (*P<0.001)[3]
- *Safety*: 38% lower infection risk (OR 0.62) and 59% reduced gonadal toxicity (OR 0.41)[3]
- *Renal preservation*: High-dose regimens marginally reduced doubling of serum creatinine (OR 2.43), though without significant remission rate differences[3].
Pediatric-Specific Outcomes
A 2024 multicenter study of 145 childhood-onset LN patients found no difference in 12-month complete renal response between EuroLupus (cumulative dose: 3 g) and NIH regimens (cumulative dose: 9–12 g) (OR 0.76; 95% CI 0.29–1.98)[5]. This challenges historical preferences for higher dosing in pediatric populations, advocating for reduced cumulative exposure without compromising efficacy.
Safety Profile and Adverse Event Mitigation
Reduced Toxicity with Pulse Administration
Cyclophosphamide’s adverse events are dose-dependent. Pulse regimens (cumulative dose: 6–12 g) demonstrate:
- *Infections*: 15% incidence vs. 26% with oral cyclophosphamide[8]
- *Gonadal toxicity*: 59% risk reduction vs. continuous dosing[3]
- *Leukopenia*: 45% lower odds (OR 0.55)[3].
Gastrointestinal and Hematologic Tolerability
Combining low-dose cyclophosphamide (0.4 g/m²) with mycophenolate mofetil (MMF) (1 g/day) reduced gastrointestinal reactions (7.1% vs. 30% with cyclophosphamide alone; P<0.05) and infections (11.9% vs. 32.5%) while maintaining equivalent remission rates[4].
---
Relapse Rates and Maintenance Strategies
Post-Remission Outcomes
The EuroLupus protocol achieved 58% complete remission in Tunisian LN patients, but 38.5% relapsed within 12 months, often due to treatment withdrawal or infections[6]. This highlights the critical role of maintenance therapy:
- *Azathioprine/MMF transition*: Post-induction maintenance with azathioprine (2 mg/kg/day) or MMF (2 g/day) sustains remission in 70–80% of cases[1][6].
- *B cell monitoring: Post-rituximab/cyclophosphamide belimumab maintenance reduces naive B cell repopulation (geometric mean: 53 vs. 11 cells/μl without belimumab; *P=0.0012)[2], potentially lowering relapse risk.
---
Placebo Comparisons and Historical Context
While direct placebo-controlled trials are limited in modern LN studies due to ethical concerns, historical data contextualize cyclophosphamide’s superiority:
- Pre-cyclophosphamide eras saw <30% 5-year renal survival in proliferative LN vs. >80% with current protocols[7].
- Indirect comparisons show placebo-equivalent regimens (e.g., corticosteroids alone) fail to prevent ESRD progression, with doubling of serum creatinine in 40–60% within 5 years[1][7].
---
Cost-Effectiveness and Accessibility
Resource-Limited Settings
Oral cyclophosphamide pulse therapy offers a cost-effective alternative to IV administration (50 INR vs. 630 INR per dose) with comparable efficacy[1][7]. This expands access in regions lacking infusion infrastructure without compromising outcomes.
---
Conclusion
Cyclophosphamide pulse therapy, particularly when combined with methylprednisolone, establishes remission in >80% of proliferative LN cases, outperforming methylprednisolone monotherapy and historical placebo-equivalent approaches. The EuroLupus protocol’s efficacy parity with high-dose regimens, coupled with superior safety, positions it as the preferred induction strategy. Future research should optimize maintenance protocols integrating biologics like belimumab to address relapse rates while minimizing cumulative toxicity.
Sources
[1] The outcome of proliferative lupus nephritis with pulse ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3161432/
[2] Phase II Randomized Trial of Rituximab Plus Cyclophosphamide ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41466
[3] A Meta-Analysis of Randomized Controlled Trials - PubMed https://pubmed.ncbi.nlm.nih.gov/31702519/
[4] Efficacy and safety of cyclophosphamide combined with ... https://pmc.ncbi.nlm.nih.gov/articles/PMC4723952/
[5] Renal Response Outcomes of the EuroLupus and National Institutes ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42725
[6] AB0369 Evaluation of the eurolupus protocol in lupus nephritis ... https://ard.bmj.com/content/72/Suppl_3/A900.2
[7] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://onlinelibrary.wiley.com/doi/10.1155/2022/8345737
[8] High Dose Cyclophosphamide versus Monthly Intravenous ... https://pmc.ncbi.nlm.nih.gov/articles/PMC2911961/
[9] Randomized controlled trial of pulse intravenous cyclophosphamide ... https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1797.2005.00444.x
[10] Treatments for Lupus Nephritis: A Systematic Review and Network ... https://www.jrheum.org/content/43/10/1801
[11] [PDF] Intravenous Cyclophosphamide for lupus nephritis - Nefrología https://www.revistanefrologia.com/index.php?p=revista&tipo=pdf-simple&pii=X2013251407020823
[12] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://pmc.ncbi.nlm.nih.gov/articles/PMC9192236/
[13] Pro: Cyclophosphamide in lupus nephritis - Oxford Academic https://academic.oup.com/ndt/article/31/7/1047/1752196
[14] Lupus Nephritis Treatment & Management - Medscape Reference https://emedicine.medscape.com/article/330369-treatment
[15] [PDF] KDIGO-2024-Lupus-Nephritis-Guideline.pdf https://kdigo.org/wp-content/uploads/2024/01/KDIGO-2024-Lupus-Nephritis-Guideline.pdf
[16] Effect of Tacrolimus vs Intravenous Cyclophosphamide on Complete ... https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790507
[17] Treatment of lupus nephritis: a meta-analysis of clinical trials - PubMed https://pubmed.ncbi.nlm.nih.gov/9016889/
[18] Moderator's view: Cyclophosphamide in lupus nephritis https://academic.oup.com/ndt/article/31/7/1058/1752165
[19] Cyclophosphamide in lupus nephritis: a controlled trial - PubMed https://pubmed.ncbi.nlm.nih.gov/4104337/
[20] Calcineurin inhibitors may be a reasonable alternative to ... https://www.spandidos-publications.com/10.3892/etm.2014.1669
[21] Induction and Maintenance Treatment of Lupus Nephritis - MDPI https://www.mdpi.com/2077-0383/11/2/343
[22] Con: Cyclophosphamide for the treatment of lupus nephritis https://academic.oup.com/ndt/article/31/7/1053/1752174
[23] Mycophenolate versus Cyclophosphamide for Lupus Nephritis https://indianjnephrol.org/mycophenolate-versus-cyclophosphamide-for-lupus-nephritis/
[24] IV Cyclophosphamide Protocols for Systemic Lupus Erythematosus https://www.msdmanuals.com/professional/multimedia/table/iv-cyclophosphamide-protocols-for-systemic-lupus-erythematosus
[25] the Euro-Lupus Nephritis Trial, a randomized trial of low-dose ... https://pubmed.ncbi.nlm.nih.gov/12209517/
[26] Current and Emerging Therapies for Lupus Nephritis - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5042683/
[27] Use of EuroLupus Cyclophosphamide Dosing for the Treatment of ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10464387/
[28] The NIH pulse cyclophosphamide regime: the end of an era? https://journals.sagepub.com/doi/10.1191/0961203304lu524ed?icid=int.sj-abstract.similar-articles.8
[29] Brief Report: The Euro‐Lupus Low‐Dose Intravenous ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.40079
[01/03, 10.42] PPM 2 - Can AI simplify it with numbers laid out clearly?
[01/03, 10.49] PPM 3 - @Meta AI simplify this high quality evidence based data with laid numbers clearly so that MBBS student can understand.
[01/03, 10.50] PPM 3 -
@Meta AI simplify this high quality evidence based medical data with laid out numbers clearly so that MBBS student can understand it better. Efficacy of Cyclophosphamide Pulse Therapy in Lupus Nephritis: Comparative Analysis Against Methylprednisolone and Placebo
Cyclophosphamide pulse therapy remains a cornerstone in the management of lupus nephritis (LN), demonstrating superior efficacy over methylprednisolone monotherapy and placebo in preserving renal function, inducing remission, and reducing relapse rates. High-quality evidence from randomized trials and meta-analyses supports its role as a first-line induction therapy, particularly in proliferative LN classes III/IV. This report synthesizes data on dosing strategies, combination regimens, safety profiles, and long-term outcomes to delineate cyclophosphamide’s therapeutic advantages.
Cyclophosphamide-Methylprednisolone Synergy in Induction Therapy
Superior Remission Rates with Combination Regimens
Combining cyclophosphamide pulses with intravenous methylprednisolone significantly enhances remission rates compared to methylprednisolone alone. In a 38-month observational study of 39 proliferative LN patients, 82.05% achieved remission (51.28% complete, 30.77% partial) following induction with methylprednisolone and monthly cyclophosphamide pulses (target cumulative dose: 200 mg/kg). Early initiation (<6 months from diagnosis) correlated with higher remission likelihood (P=0.04), underscoring the time-sensitive nature of aggressive immunosuppression[1]. Mechanistically, cyclophosphamide suppresses lymphocyte proliferation, complementing methylprednisolone’s anti-inflammatory effects to reduce glomerular immune complex deposition.
Head-to-Head Comparisons with Methylprednisolone Monotherapy
Methylprednisolone alone demonstrates inadequate disease control in severe LN. In refractory cases, a phase II trial comparing rituximab/cyclophosphamide (RC) versus rituximab/cyclophosphamide/belimumab (RCB) found no significant difference in renal response rates (RCB: 52%, RC: 41%; P=0.452), highlighting cyclophosphamide’s irreplaceable role even in biologic combination regimens[2]. Notably, 73% of treatment failures stemmed from lack of improvement or worsening LN, emphasizing the necessity of cyclophosphamide’s cytotoxic action in halting autoimmune renal damage.
Pulse vs. Continuous Cyclophosphamide Regimens
Meta-Analysis of Dosing Strategies
A meta-analysis of 12 randomized trials (994 patients) revealed distinct advantages of short-interval, lower-dose intravenous cyclophosphamide (e.g., EuroLupus protocol: 500 mg fortnightly for 3 months) over traditional high-dose regimens:
- *24-hour proteinuria reduction: Mean difference -0.45 g/day (*P<0.001)[3]
- *Safety*: 38% lower infection risk (OR 0.62) and 59% reduced gonadal toxicity (OR 0.41)[3]
- *Renal preservation*: High-dose regimens marginally reduced doubling of serum creatinine (OR 2.43), though without significant remission rate differences[3].
Pediatric-Specific Outcomes
A 2024 multicenter study of 145 childhood-onset LN patients found no difference in 12-month complete renal response between EuroLupus (cumulative dose: 3 g) and NIH regimens (cumulative dose: 9–12 g) (OR 0.76; 95% CI 0.29–1.98)[5]. This challenges historical preferences for higher dosing in pediatric populations, advocating for reduced cumulative exposure without compromising efficacy.
Safety Profile and Adverse Event Mitigation
Reduced Toxicity with Pulse Administration
Cyclophosphamide’s adverse events are dose-dependent. Pulse regimens (cumulative dose: 6–12 g) demonstrate:
- *Infections*: 15% incidence vs. 26% with oral cyclophosphamide[8]
- *Gonadal toxicity*: 59% risk reduction vs. continuous dosing[3]
- *Leukopenia*: 45% lower odds (OR 0.55)[3].
Gastrointestinal and Hematologic Tolerability
Combining low-dose cyclophosphamide (0.4 g/m²) with mycophenolate mofetil (MMF) (1 g/day) reduced gastrointestinal reactions (7.1% vs. 30% with cyclophosphamide alone; P<0.05) and infections (11.9% vs. 32.5%) while maintaining equivalent remission rates[4].
---
Relapse Rates and Maintenance Strategies
Post-Remission Outcomes
The EuroLupus protocol achieved 58% complete remission in Tunisian LN patients, but 38.5% relapsed within 12 months, often due to treatment withdrawal or infections[6]. This highlights the critical role of maintenance therapy:
- *Azathioprine/MMF transition*: Post-induction maintenance with azathioprine (2 mg/kg/day) or MMF (2 g/day) sustains remission in 70–80% of cases[1][6].
- *B cell monitoring: Post-rituximab/cyclophosphamide belimumab maintenance reduces naive B cell repopulation (geometric mean: 53 vs. 11 cells/μl without belimumab; *P=0.0012)[2], potentially lowering relapse risk.
---
Placebo Comparisons and Historical Context
While direct placebo-controlled trials are limited in modern LN studies due to ethical concerns, historical data contextualize cyclophosphamide’s superiority:
- Pre-cyclophosphamide eras saw <30% 5-year renal survival in proliferative LN vs. >80% with current protocols[7].
- Indirect comparisons show placebo-equivalent regimens (e.g., corticosteroids alone) fail to prevent ESRD progression, with doubling of serum creatinine in 40–60% within 5 years[1][7].
---
Cost-Effectiveness and Accessibility
Resource-Limited Settings
Oral cyclophosphamide pulse therapy offers a cost-effective alternative to IV administration (50 INR vs. 630 INR per dose) with comparable efficacy[1][7]. This expands access in regions lacking infusion infrastructure without compromising outcomes.
---
Conclusion
Cyclophosphamide pulse therapy, particularly when combined with methylprednisolone, establishes remission in >80% of proliferative LN cases, outperforming methylprednisolone monotherapy and historical placebo-equivalent approaches. The EuroLupus protocol’s efficacy parity with high-dose regimens, coupled with superior safety, positions it as the preferred induction strategy. Future research should optimize maintenance protocols integrating biologics like belimumab to address relapse rates while minimizing cumulative toxicity.
Sources
[1] The outcome of proliferative lupus nephritis with pulse ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3161432/
[2] Phase II Randomized Trial of Rituximab Plus Cyclophosphamide ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.41466
[3] A Meta-Analysis of Randomized Controlled Trials - PubMed https://pubmed.ncbi.nlm.nih.gov/31702519/
[4] Efficacy and safety of cyclophosphamide combined with ... https://pmc.ncbi.nlm.nih.gov/articles/PMC4723952/
[5] Renal Response Outcomes of the EuroLupus and National Institutes ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42725
[6] AB0369 Evaluation of the eurolupus protocol in lupus nephritis ... https://ard.bmj.com/content/72/Suppl_3/A900.2
[7] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://onlinelibrary.wiley.com/doi/10.1155/2022/8345737
[8] High Dose Cyclophosphamide versus Monthly Intravenous ... https://pmc.ncbi.nlm.nih.gov/articles/PMC2911961/
[9] Randomized controlled trial of pulse intravenous cyclophosphamide ... https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1797.2005.00444.x
[10] Treatments for Lupus Nephritis: A Systematic Review and Network ... https://www.jrheum.org/content/43/10/1801
[11] [PDF] Intravenous Cyclophosphamide for lupus nephritis - Nefrología https://www.revistanefrologia.com/index.php?p=revista&tipo=pdf-simple&pii=X2013251407020823
[12] Revisited Cyclophosphamide in the Treatment of Lupus Nephritis https://pmc.ncbi.nlm.nih.gov/articles/PMC9192236/
[13] Pro: Cyclophosphamide in lupus nephritis - Oxford Academic https://academic.oup.com/ndt/article/31/7/1047/1752196
[14] Lupus Nephritis Treatment & Management - Medscape Reference https://emedicine.medscape.com/article/330369-treatment
[15] [PDF] KDIGO-2024-Lupus-Nephritis-Guideline.pdf https://kdigo.org/wp-content/uploads/2024/01/KDIGO-2024-Lupus-Nephritis-Guideline.pdf
[16] Effect of Tacrolimus vs Intravenous Cyclophosphamide on Complete ... https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790507
[17] Treatment of lupus nephritis: a meta-analysis of clinical trials - PubMed https://pubmed.ncbi.nlm.nih.gov/9016889/
[18] Moderator's view: Cyclophosphamide in lupus nephritis https://academic.oup.com/ndt/article/31/7/1058/1752165
[19] Cyclophosphamide in lupus nephritis: a controlled trial - PubMed https://pubmed.ncbi.nlm.nih.gov/4104337/
[20] Calcineurin inhibitors may be a reasonable alternative to ... https://www.spandidos-publications.com/10.3892/etm.2014.1669
[21] Induction and Maintenance Treatment of Lupus Nephritis - MDPI https://www.mdpi.com/2077-0383/11/2/343
[22] Con: Cyclophosphamide for the treatment of lupus nephritis https://academic.oup.com/ndt/article/31/7/1053/1752174
[23] Mycophenolate versus Cyclophosphamide for Lupus Nephritis https://indianjnephrol.org/mycophenolate-versus-cyclophosphamide-for-lupus-nephritis/
[24] IV Cyclophosphamide Protocols for Systemic Lupus Erythematosus https://www.msdmanuals.com/professional/multimedia/table/iv-cyclophosphamide-protocols-for-systemic-lupus-erythematosus
[25] the Euro-Lupus Nephritis Trial, a randomized trial of low-dose ... https://pubmed.ncbi.nlm.nih.gov/12209517/
[26] Current and Emerging Therapies for Lupus Nephritis - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5042683/
[27] Use of EuroLupus Cyclophosphamide Dosing for the Treatment of ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10464387/
[28] The NIH pulse cyclophosphamide regime: the end of an era? https://journals.sagepub.com/doi/10.1191/0961203304lu524ed?icid=int.sj-abstract.similar-articles.8
[29] Brief Report: The Euro‐Lupus Low‐Dose Intravenous ... https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.40079
1. Cyclophosphamide + Methylprednisolone: A Powerful Combination
• Effectiveness:
• A study of 39 LN patients showed 82% remission when treated with monthly cyclophosphamide + methylprednisolone for 38 months.
• Early treatment (within 6 months) significantly improves outcomes (P = 0.04).
• Why This Works?
• Cyclophosphamide: Kills immune cells attacking the kidney.
• Methylprednisolone: Reduces inflammation and immune complex deposits in the kidney.
• Methylprednisolone Alone is Weaker:
• A study found that even with biologics (e.g., rituximab), cyclophosphamide remains essential in severe cases.
2. Different Dosing Strategies for Cyclophosphamide
There are two main ways to give cyclophosphamide:
A. High-Dose (NIH Protocol)
• Dose: 0.5–1 g/m² every month for 6–12 months (total dose: 9–12 g).
• Better at preserving kidneys long-term but has more side effects.
B. Low-Dose (EuroLupus Protocol)
• Dose: 500 mg every 2 weeks for 3 months (total dose: 3 g).
• Similar effectiveness but fewer side effects.
• Meta-Analysis (12 studies, 994 patients) showed:
• Both regimens have similar remission rates.
• Low-dose cyclophosphamide is safer:
• 38% lower infection risk.
• 59% less gonadal toxicity (risk of infertility).
• For children:
• A 2024 study on 145 pediatric LN patients found no difference in remission between low-dose and high-dose cyclophosphamide.
• This suggests low-dose should be preferred due to fewer side effects.
3. Safety and Side Effects of Cyclophosphamide
• Pulse therapy (intermittent IV doses) has fewer side effects than daily oral doses.
• Common Side Effects and Reduction Strategies:
Side Effect How Often? How to Reduce?
Infections 15% (IV) vs. 26% (oral) Low-dose protocol, antibiotics if needed.
Infertility risk 59% lower in low-dose Use gonadotropin-releasing hormone agonists (GnRH agonists).
Leukopenia (low WBC count) 45% lower in low-dose Regular blood count monitoring.
Gastrointestinal issues 30% in high-dose Add mycophenolate mofetil (MMF) to therapy.
4. Relapses and Long-Term Maintenance
• Even after remission, relapse happens in ~38.5% of patients (especially if therapy is stopped early).
• Best Maintenance Therapies:
• Azathioprine (2 mg/kg/day) or Mycophenolate Mofetil (2 g/day) maintain remission in 70–80% of patients.
• Biologics (e.g., belimumab) help prevent B cell repopulation, reducing relapse risk.
5. Cyclophosphamide vs. Placebo (Historical Context)
• Before cyclophosphamide, only 30% of severe LN patients survived 5 years.
• With modern protocols, survival is >80%.
• Methylprednisolone alone or placebo-like treatments lead to kidney failure in 40–60% of patients within 5 years.
6. Cost and Accessibility
• Oral cyclophosphamide pulse therapy is a cheaper alternative to IV (50 INR vs. 630 INR per dose) with similar effectiveness.
• This makes it an excellent choice in low-resource settings.
7. Final Takeaway
• Cyclophosphamide pulse therapy + methylprednisolone is the best induction treatment for severe lupus nephritis.
• The EuroLupus protocol (low-dose IV cyclophosphamide) is as effective as high-dose regimens but much safer.
• Maintenance therapy (azathioprine/MMF) is crucial to prevent relapses.
By chat GPT sir.
[01/03, 10.54] PPM 2 - Lovely mate! Thanks a ton.
[01/03, 16.29] PPM 1 - That's why we need to check out those global thesis.
[01/03, 16.39] PPM 1 - Thanks @PPM3
@PPM16 @PPM2 if you go through these inputs from AI in the context of our patient, our patient has already demonstrated achievable remission induction in her last visits with proteinuria touching 200 mg near remission. The issue was with maintenance and while she was lucky with the remission front with steroids and azathioprine she developed pancreatitis and hence we just need to switch into another modality to reinstate remission and maintain it.
The trouble with cyclophosphamide is the cumulative gonadal toxicity so we can use it to achieve remission to begin with even using oral now and then once we reach the gonadal cumulative limit as well as document remission in the coming three months we can then switch to the expensive mycofenolate mofetil?
[01/03, 20.47] PPM 3 - My critical thought is to educate attenders regarding cumulative side effects of cyclophosphamide and expensiveness of MMF for maintainance therapy and efficacies of both. Let them understand the current complexities in therapeutic decision making and let them be part of this process sir.
PPM 1 - 👍
@PPM19 Joined this group.
PPM 19 - Thank you @PPM1.
PPM 1 - Welcome Ma'am.
Please go through the description box here and do share your queries on our workflow.
We generally keep sharing certain portals to our patient centred medical cognition workflow here from time to time and depends on one's interest a group member is free to provide their own inputs on the patient here or even get into the group marked for that particular individual.
For example I'm resharing a conversational transcript posted today morning about one of our current inpatients here 👇
Morning PaJR session on a young patient with indolent lupus nephritis responsive to azathioprine and yet developing possible pancreatitis due to cumulative dose toxicity looking for other lower cost alternatives such as cyclophosphamide and yet she's a young unmarried woman where cyclophosphamide runs the risk of gonadal toxicity:
https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1
[27/02, 07:30: Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating
However having said that I guess we should stop azathioprine for now
Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission
[27/02, 14:35] pg: Can we plan renal biospy for her sir?!
[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.
Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today
So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!
Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!
[28/02, 14:24}pm - @PPM3 you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @PPM18 also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.
We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @PPM5 just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet
[28/02, 15:55]PPM 3 : Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.
[28/02, 15:59] PPM 3: Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir.
[01/03, 08:19] PPM 16: In summary, the cumulative exposure to CYC that
results in ovarian failure varies by age. To avoid
amenorrhea, female patients < 20 years old should
likely receive < 15 to 20 g of total exposure, patients
aged 20 to 30 should receive < 15 g of total exposure
and those > 30 should likely receive < 10 g of total
exposure. We did not make a recommendation for
maximum exposure to prevent infertility in patients
> 40 as this group already has a low baseline fertility
rate, worsened by disease activity. In males, the
maximum CYC exposure for patients who still wish to
conceive is lower at approximately 10 g.
http://www.bcrenal.ca/resource-gallery/Documents/Gonadal%20Toxicity%20with%20Cyclophosphamide.pdf
[01/03, 08:23] PPM 16: We are just calculating the cost of tablets sir. Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..
[01/03, 08:26] pm: So the harms appear to be worth a try!
Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil
[01/03, 08:28] pm: As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks!
[01/03, 08:31] PPM 16: Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...
So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based...
In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....
01-03-2025
Other CBBLE group conversations.
[01/03, 10:06] rk: How this case relevant to META AI or LLM ???
[01/03, 10:06]ek: Just curious
[01/03, 16:50] cm: The opening comment about meta AI (LLM) comes after a few more inputs visible in sequence in the case report where the team based learning members of the patient's PaJR group were discussing the diagnostic uncertainty around the patient's pain abdomen and vomiting where the team had initially gone in the direction of inflammatory bowel disease causing intestinal obstruction and vomiting and pain before one of the members clarified using meta AI that possibly it was her steroids and cumulative dose of azathioprine that was precipitating her pancreatitis and we were actually dealing with a smoldering pancreatitis which made the treating team stop her azathioprine resulting in her recovery!
The subsequent conversations today are around the next step to find a pharmacological replacement for her azathioprine that had to be stopped.
03-03-2025
[03-03-2025 03:40] PPM 2: https://pubmed.ncbi.nlm.nih.gov/9436862/
"In the serum samples collected on days 0-1 after the onset of symptoms, lipase was elevated in 100% and amylase in 95%. A 95% sensitivity/specificity was reached at a lipase cutoff near twofold above normal. The receiver-operating characteristics (ROC) showed similar curves for both enzymes, lipase being slightly superior to amylase. The ROC curves from days 2-3 demonstrated a much lower sensitivity/specificity of both enzymes. Lipase, however, was notably superior to amylase: at a sensitivity of 85% the specificity of lipase (amylase) was 82% (68%). In samples from days 4-5 the accuracy of the enzyme assays was even worse; at a sensitivity of 60% the specificity did not increase above 70%."
PPM 1 - 👏
[03-03-2025 08:09] PPM 1: Beautiful! Just as we suspected!
[12-03-2025 16.14] PPM 1: Urine proteinuria on 27/2/25
24 hour creatinine on 27/2/25
[12-03-2025 16.22] PPM 1: Near remission of proteinuria on 1/3/25. Renal biopsy done on 7/1/25
[23-03-2025 12:50] PA: Gd afternoon sir and madam ninna iron tblt vesukunna ninna 1time vomtings
aenae eroju moham kadupu vampu vchindi
[23-03-2025 17:54] PPM 1: Let her hold the iron tablets for now.
When did she start taking them?
[23-03-2025 17:55] PPM 3: Since Yesterday sir, told to withhold as of now.
[23-03-2025 17:56] PPM 1: 👍Why yesterday!
[23-03-2025 18:28] PPM 3: Yesterday patient father called me in view of nausea and vomiting after
taking iron tablet which was taken yesterday first time after discharge. Reassured and advised to stop
iron tablet as of now sir
PPM 1 - 👍
[12-04-2025 12.04] PPM 1: Reviewing now in OPD:
Asymptomatic after her last debacle when we had to admit her for recurrent abdominal pain and then stop her azathioprine assuming it's azathioprine induced recurrent pancreatitis!
Same sitting we also did her renal biopsy and now that she was out of sight and out of mind for a month we suddenly realised we didn't see that report! @~PPM 5 @~PPM 4
[12-04-2025 12.07] PPM 1: She's moving around with the tissue blocks which appears to have been provided to her by the Nalgonda lab where it was deposited!
Now please let's show these blocks to our pathology lab here in our campus
[12-04-202512.22] PPM 1: Talked to the father just now @~PPM 9 @~PPM 16
He deposited the renal biopsy tissue in that lab and paid the money but didn't collect any bill and yesterday once he reached that lab for the report they simply handed him this packet containing blocks!
[12-04-2025 12:32] PPM 4: Sir the pathologist at nalgonda said she usually dont report renal biopsy
So she sent back the blocks asking them to get reported at other center
[12-04-2025 12:33] PPM 1: This is terrible isn't it! 😨
[12-04-2025 12:34] PPM 4: We asked the attender to collect the report multiple times in the past few weeks sir. We thought they are a bit busy and will come to us with the report
[12-04-2025 12:39] PPM 9: Yes sir that too after repeated calls and msgs they went yesterday to collect the report sir
[12-04-2025 12:41] PPM 3: In which lab sample was given Govt lab or Raju @ thyrocare..?
[12-04-2025 12:41] PPM 20: Jagruthi diagnostics sir
[12-04-2025 12:43] PPM 4: At Thyrocare
They dont prepare the blocks and slides sir
[12-04-2025 12:44] PPM 3: Usually we send biopsy samples to KHL right..? What made us to out source sample this time..?
[12-04-2025 12:46] PPM 20: Contacted thyrocare now sir they said they give report after 1 week with cost of 800 sir
[12-04-2025 12:46] PPM 1: Why didn't we verify that Jagruti diagnostics doesn't do renal biopsy reporting?
[12-04-2025 12:47] PPM 1: Now we are sending the blocks to our campus pathology. Not sure how much they charge
[12-04-2025 12:48] PPM 20: Khl costs around 3k sir whereas in NLG it is costing around 1500 sir
[13-04-2025 14:21] PPM 1: What about our area? To KHL we can send just the immuno florescence part?
Also from what we know now there's no expertise in NLG to see these histopathology specimens particularly renal biopsy. I'm sure we may have a better light microscopy expertise here in our area.
[13-04-2025 14:22] PPM 1: Why didn't we talk to Dr KC and ask where he would prefer to send his biopsies or where does he send his biopsies that he does in other centres
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