INTRODUCTION Lupus nephritis: is an inflammation of the kidney caused by systemic lupus erythematosus (SLE), a disease of the immune system.

It affects the skin, joints and brain as well as the kidneys. The kidney damage caused by systemic lupus erythematosus is called lupus nephritis. Lupus nephritis affects 50 out of every 100,000 people and, in China, the number is 70 out of every 100,000 people. SLE may damage different parts of the kidney, leading to interstitial nephritis, nephritic syndrome and membranous GN. It may rapidly worsen to kidney failure. SLE is more common in women than men (male: female=1:9), with a high incidence among young women (age 20-30). The causes of SLE are still unknown, so there is still no effective treatment. In recent years, a treatment of a combination of traditional Chinese and western medicine has got great achievements, and the prognosis has improved a lot. If proper diagnose and treatment are done, the survival rate of SLE patients in 5-10 year will improve from 20%-40% to 74.6-81.1%.

Symptoms of lupus nephritis

Although the consequences of untreated lupus nephritis are serious, the symptoms are not always dramatic. They can vary from person to person and even from day to day in the same person. Symptoms include:

Weight gain; High blood pressure; Swelling around the legs, eyes, ankles or fingers. This is often the first noticeable symptom. The swelling is usually absent in the morning. It gradually gets worse as a person walks about during the day. Dark urine; Foamy, frothy urine and the need to get up to urinate during the night can suggest a loss of protein in the urine.

Diagnosis The diagnosis of lupus nephritis may require urine and blood tests as well as a kidney biopsy and X-rays.

X-rays of the kidneys Blood tests. These are done to see if the kidney is effectively removing waste products from the blood. Additionally, if there is a loss of protein in the urine, a blood test can show if there is a lower level of protein in the blood. Blood tests can also show is there are imbalances of salt and water in the blood. Finally, blood tests can show the presence of antibodies that are typically high in persons who have lupus nephritis.

Urine tests. A urinalysis is the simplest and most common test used to find out if a person has lupus nephritis. A urinalysis will check for the presence of red and white blood cells in the urine or high levels of protein. Blood or protein in the urine is a sign of kidney damage.

Imaging studies. Two of these types of studies - an intravenous pyelogram and a sonogram - are usually done before a kidney biopsy. In an intravenous pyelogram, dye is injected into the body and collects in the kidneys. An X-ray is taken that shows the outline of the kidneys with the dye. A sonogram uses sound waves transmitted through the body and their echoes to show the shape and size of the surfaces of the kidney.

A biopsy of the kidney. This test involves taking a sample of kidney tissue to examine under a microscope. If blood and urine studies suggest lupus nephritis, a biopsy is done to confirm the diagnosis. A biopsy can also help find out how widespread and severe the kidney disease is. A biopsy is most often done by inserting a narrow needle through the skin of the back and removing a small piece of kidney. (Rarely, the procedure may be done in an operating room surgically.)

Treatment

Treatment depends on the symptoms and must be tailored to the individual. Medicines can decrease swelling, lower blood pressure, and decrease inflammation by suppressing the immune system. Sometimes drugs to prevent blood clots are also prescribed. High doses of corticosteroids may be prescribed until the lupus nephritis improves. Because corticosteroids can cause a variety of side effects including fluid retention, moodiness, loss of mineral from the bones and cataracts, they must be monitored carefully. The dosage of corticosteroids prescribed for lupus nephritis is usually tapered down once the symptoms improve. Another type of drug that may be prescribed is cytotoxic drugs or drugs that suppress the immune system. These are typically given to people who have lupus nephritis to prevent kidney damage. Patients may need to limit protein, sodium and potassium intake in their diet. Maintaining a healthy weight is also important.

Even with treatment, some people with lupus nephritis continue to lose kidney function. In the event that both kidneys fail, it may be necessary to have dialysis. Dialysis involves filtering the blood through a machine so that waste products can be removed from it before the blood is returned to the body. Ultimately, kidney transplantation may be needed. Persons with lupus can successfully have kidney transplantation if the surgery is done at a point in time where they do not have active lupus. After transplantation, they will need drugs to suppress the body's immune system to avoid having the transplanted kidney rejected. Thanks to major advances in understand and treatment of lupus nephritis, more than 80% of people with lupus nephritis will live a normal life span.

. Classification of lupus nephritis In order to distinguish different types of lupus nephritis, World Health Organization released a classification of lupus nephritis in 1982. Class I lupus nephritis is defined as minimal mesangial lupus nephritis with accumulation of mesangial immune complexes by immunofluorescence. Thus a complete lack of renal abnormalities by light microscopy, IF and EM now no longer qualifies for class I as in 1974 WHO classification. Class II lupus nephritis is defined as mesangio-proliferative lupus nephritis characterized by any degree of mesangial hypercellularity associated with mesangial immune deposits. Class III lupus nephritis is defined as focal lupus nephritis involving 50% glomeruli which display segmental endocapillary proliferative lesion or inactive glomerular scars with or without capillary loop necrosis or crescents and is usually accompanied with segmental sub endothelial deposits on IF. Class IV lupus nephritis is defined as diffuse proliferative nephritis involving 50% glomeruli exhibiting segmental or global proliferation. Activity and chronicity features should be mentioned in the diagnostic description. The morphologic description should contain the proportion of glomeruli affected by active and chronic lesions and by fibrinoid necrosis and crescents; tubulointerstitial and vascular pathology should also be indicated in the diagnostic description. Class V lupus nephritis is defined as membranous nephritis with global or segmental continuous granular sub epithelial immune deposits and often concomitant mesangial immune deposits. Any degree of mesangial hypercellularity can occur in class V along with scattered sub endothelial deposits which when present, warrant a diagnosis combined class III or IV with class V. Class VI lupus nephritis also designated as advanced stage lupus nephritis, require90% global glomerulosclerosis to occur in the biopsies where there is clinical or pathologic evidence that the sclerosis is attributable to lupus nephritis. There should be no evidence of ongoing active glomerular disease. Without the availability of sequential renal biopsies, it may be impossible to determine the basic cause of sclerotic glomerular

lesions.

Proper diet of lupus nephritis 1. Avoid high fat diet. Fat will worsen arteriosclerosis and inhibit hematopoietic function, so the chronic nephritis patients should not take too much. But if the patients have no intake of fat, it will result in malnutrition. So, the patients can take vegetable oil to replace animal tallow in daily life, about 60g per day. 2. Limit the intake of salt The daily intake of salt should be limited to 2-4 g, which will be helpful to prevent the worsening of edema and hypervolemia. 3. Avoid the food rich in purine and nitrogen If the patients take the food rich in purine and nitrogen, then its metabolite could not be discharged timely, which will have a negative effect on kidney function. These kinds of food include Spinach, celery, radish, beans, soy, fish soup, and chicken soup, sardines. 4. Avoid strong seasoning The strong seasoning such as pepper, mustard and chili are unfavorable to kidney function. 5. Limit the intake of plant proteins For the patients with lupus nephritis, the intake of protein should depend on the damage level of kidney. When the patients get the symptoms of oliguria, edema, hypertension or nitrogen, the daily intake of protein should be controlled to 20-40g to reduce the burden of kidney and avoid the deposit of nonprotein nitrogen. 6. Limit the intake of liquid If the patient is affected by hypertension and edema, then he should limit the intake of liquid. When lupus nephritis attack, the kidney function will be damaged, which will disable the discharge of the liquid in the body and worsen the edema.

Attention the toxicity of the medicine For the patients with lupous genetic basic, they should pay attention to the toxicity of the medicine. Avoid insolation: Uviolize will worsen the lupus nephritis. So, in daily life, the patients with lupus nephritis should avoid insolation under the intense sunshine to lessen the kidney damage that caused by the uviolize. Diet: The patients with lupus nephritis should take enough nutrition, such as protein, vitamin, and mineral substance. Water and salt should be properly limited. Avoid abundant cigarette, alcoholic drink or stimulating food. Exercise: Doing exercise can promote the blood circulation, enhance the cardiorespiratory function and keep the toughness of muscle and bones, all of which are helpful to anyone, patients are no exception. But the patients should not do the strenuous exercise and be not overtired.

Prevent infection For the effect of the disease or the side effects of steroid or immunodepressant, the immunocompetence of the patients drop, so the patient are easily affected by bacterium and cause the infection of various organs. keep up good spirits The emotion has a close relationship with disease. The patients should keep up good spirits.

Uremia: Uremia is the last stage of chronic nephritis. Most of the patients and doctors may know that if the SCr is higher than 707umol/L, then the kidney replacement treatment should be conducted, that is, hemodialysis, Peritoneal dialysis and kidney transplantation. The kidney replacement is the last choice to choose. This therapy can only prolong the lifespan of the patients, but could not cure the uremia. Long-term of hemodialysis will make the remaining kidney harden and then lose the best chance of treatment. When the patients get GFR6-10ml/min SCr>707umol/L and has evident symptoms of uremia, the doctor should conduct the treatment that will deal with all the complications and protect the kidney function. Try every possibility to protect the remaining kidney unit, strengthen the renal activity, which will help to restore the renal function gradually.

Let Them Eat During Dialysis: An Overlooked Opportunity to Improve Outcomes in Maintenance Hemodialysis Patients
In individuals with chronic kidney disease, surrogates of protein-energy wasting, including a relatively low serum albumin and fat or muscle wasting, are by far the strongest death risk factor compared with any other condition. There are data to indicate that hypoalbuminemia responds to nutritional interventions, which may save lives in the long run. Monitored, in-center provision of high-protein meals and/or oral nutritional supplements during hemodialysis is a feasible, inexpensive, and patient-friendly strategy despite concerns such as postprandial hypotension, aspiration risk, infection control and hygiene, dialysis staff burden, diabetes and phosphorus control, and financial constraints. Adjunct pharmacologic therapies can be added, including appetite stimulators (megesterol, ghrelin, and mirtazapine), anabolic hormones (testosterone and growth factors), antimyostatin agents, and antioxidative and anti-inflammatory agents (pentoxiphylline and cytokine modulators), to increase efficiency of intradialytic food and oral supplementation, although adequate evidence is still lacking. If more severe hypoalbuminemia (<3.0 g/dL) not amenable to oral interventions prevails, or if a patient is not capable of enteral interventions (e.g., because of swallowing problems), then parenteral interventions such as intradialytic parenteral nutrition can be considered. Given the fact that meals and supplements during hemodialysis would require only a small fraction of the funds currently used for dialysis patients this is also an economically feasible strategy.

Effect of a Dietitian-managed Bone Algorithm on Serum Phosphorus Level in Maintenance Hemodialysis Patients
Objective This study examined the effectiveness of a registered dietitian (RD)-managed bone metabolism algorithm compared with a non-RD (registered nurse and the nephrologist)managed one on serum phosphorus (PO4) and related clinical outcomes (corrected serum calcium [cCa] level, intact parathyroid hormone [iPTH] level, incidence of parathyroidectomy) among in-center maintenance hemodialysis (MHD) patients. Design and Setting The study was an 18-month retrospective review of adult MHD patients (n = 252) at 5 outpatient dialysis centers in western Massachusetts and Connecticut before and after change in the management of a comprehensive bone metabolism treatment algorithm (intravenous vitamin D, phosphate-binding medication, calcimimetic) from non-RD to RD. Calendar-matched timepoints representing 3-month averages during the non-RDand RD-managed periods of the same algorithm were used for analyses. Comparisons of outcomes at non-RD-managed timepoint 2 (February 2009-April 2009) and RDmanaged timepoint 6 (February 2010-April 2010) were performed considering potential demographic and clinical confounders. Results On average, serum PO4 level was lower during the RD-managed timepoint 6 (5.17 1.23 mg/dL; mean standard deviation) compared with non-RD-managed timepoint 2 (5.23 1.24 mg/dL), although the difference between these calendar-matched timepoints was not statistically significant (F = .108, P = .74) after controlling for age, dietary intake (equilibrated normalized protein catabolic rate), and dialysis adequacy (equilibrated Kdrt/V). Mean cCa at RD-managed timepoint 6 (8.76 0.65 mg/dL) was not significantly different from non-RD-managed timepoint 2 (8.79 0.74), and the difference between serum iPTH level at timepoint 6 (363.0 296.8 pg/mL) compared with timepoint 2 (319.8 251.5 pg/mL) was nonsignificant (F = .650, P = .42) after controlling for age. There were fewer parathyroidectomies during the RD-managed period (0.8%) compared with the non-RD-managed period (1.6%). Conclusions RDs may be equally effective as non-RDs in bone metabolism algorithm management with respect to serum PO4, cCa, and iPTH control in MHD patients. Further research is needed to prospectively evaluate the effect of RD management on these bone mineral outcomes.

LABORATORY

NORMAL VALUES

HEMOGLOBIN: 91 HEMATOCRIT: 0.28 WBC: 4.50 NEUTROPHILS: 0.82 LYMPHOCYTES: 0.18 PLATELET: 180 BUN: 21.52 CREATENINE: 956 SODIUM: 136 POTTASIUM: 3.90 PHOSPORUS: 3.20

F: 120-170 M: 140-170 F: 0.38-0.48 M: 0.40-0.50 5000-11000/L 54-75 2- 35 200-400 10/L 3.2 8mmol/L 53-133mmol/L 135-145mmol/L 4-4.5mmol/L 0.42- 1.97mmol/L

Anatomy of the Urinary System

Anatomy of the Urinary System

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How do the kidneys and urinary system work? The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood. The kidney and urinary systems keep chemicals, such as potassium and sodium, and water in balance and remove a type of waste, called urea, from the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys,where ii is removed. Other important functions of the kidneys include blood pressure regulation and the production of erythropoietin, which controls red blood cell production in the bone marrow.

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Kidney and urinary system parts and their functions:

two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to remove liquid waste from the blood in the form of urine; keep a stable balance of salts and other substances in the blood; and produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus , and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney. two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters. bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours. two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. nerves in the bladder - alert a person when it is time to urinate, or empty the bladder. urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs. Facts about urine:

Adults pass about a quart and a half of urine each day, depending on the fluids and foods consumed. The volume of urine formed at night is about half that formed in the daytime. Normal urine is sterile. It contains fluids, salts and waste products, but it is free of bacter ia, viruses and fungi. The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.