Discussion on latest management of lupus nephritis
(Part 1)
In this series of columns we will be having a discussion on the 2019 update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis (LN).
The objective of this series of discussions is about update of the 2012 EULAR/ERA-EDTA recommendations for the management of LN.
In updating the EULAR/EPA-EDTA standardized operating procedures, which is a systematic piece of literature review, people who are involved in a multidisciplinary Task Force decided independently on their level of agreement with the formed statements regarding the updates on the management of LN.
The proposed changes have included treatment target recommendations using glucocorticoids and calcineurin inhibitors (CNI) and management of end-stage kidney disease (ESKD).
The therapy’s target is to have complete response (proteinuria <0.5–0.7 g/24 hours with (near-) normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria.
The treatment is recommending the use of hydrochlroquine paired with regular monitoring of opthalmological condition.
In the case of active proliferative LN, the preferred initial treatment is with mycophenolate mofetil (MMF 2–3g/ day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg x 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then using oral prednisone 0.3–0.5 mg/kg/day).
MMFI CNI (especially tacrolimus) combination and high- dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. The long-term maintenance treatment using MMF or azathioprine is something that should be followed, with no or low-dose (<7.5 mg/day) glucocorticoids.
When choosing the agent for treatment, it really depends on the initial regimen and plans for pregnancy. In non-responding disease, a switch of introductory treatments or the use of rituximab is recommended. In pure membranous LN involving nephrotic-range proteinuria or proteinuria >1g/24 hours despite renin-angiotensin-aldosterone blockade, MMF with glucocorticoids is the best option.
The assessment for kidney and extra-renal disease activity, and control of comorbidities is lifelong, emphasizing the need for repeat kidney biopsy in cases where there are incomplete response or nephritic flares. In ESKD, transplantation is eyed as the best mode of action as kidney replacement option with immunosuppression using transplant protocols and/ or extra-renal presentations.
The treatment of LN in children is almost the same as adult sufferers.
As a result the EULAR/ERA-EDTA recommendations for the management of LN Is to facilitate harmonize the care of the patient suffering the said disease.
Next week, we will be starting the in-depth discussion on the proposed revised treatment and management of LN.
SARS-CoV-2, Getting to know more of our “Enemy”
The Philippine Pediatric Society Central Visayas chapter sponsored a Webinar lecture on Covid19. Different speakers were invited to talk on different topics from statistics to pathophysiology of Covid 19 to management of the infection. And for this column now, I will share with you the learnings I got on what is SARS-CoV-2 as lectured by Dr Belle M. Ranile, a Pediatric Infectious Disease Specialist based in Cebu City.
The disease caused by the virus SARS-CoV-2 is called COVID-19 (Coronavirus 2019). There are seven (7) corona viruses that may infect the human beings, 4 of which are causing the common cold and other mild respiratory infection and 3 are causing severe infections in the humans. These are:
1. MERS-CoV (the beta Coronavirus that causes Middle East Respiratory Syndrome)
2. SARS-CoV (the beta Coronavirus that causes severe acute respiratory syndrome)
3. SARS-CoV-2 (the novel beta Coronavirus that causes COVID-19)
This SARS-CoV-2 is an enveloped positive-sense, single stranded RNA virus from the family Coronaviridae. They gain entry into the host cell through the binding of the viral S protein to the host ACE 2 receptor.
They can be transmitted by contact and droplet (direct, indirect and close contact), airborne and other routes such as urine and stool. Studies are still being conducted to verify if truly this virus can be transmitted through, urine/ stool, blood borne and or vertical transmission (from the mother to the newborn through delivery).
Though, the main transmission route is through respiratory droplets. This is the main reason it is very important to wear face mask to protect oneself and to protect the others.
The main incubation period of the disease is 5 days, the symptomatic onset is between 1-14 days and the symptom duration is 6-27 days. Eighty per cent (80%) of the infected are asymptomatic to showing mild symptoms, while 15% go to severe infections and 5% becomes critical.
There are 3 stages of Covid-19 infection. Stage 1 is the early infection where the infected person will have fever, dry cough, headache and diarrhea. This stage also corresponds to the viral response phase. Stage 2 is the pulmonary phase. In this stage, the patient will have shortness of breath. Stage 3 is the hyper inflammatory phase where the patient may go into acute respiratory distress syndrome, shock and cardiac failure. This stage corresponds with the host inflammatory phase.
Dr. Ranile mentioned that the vulnerable groups are the following:
1. Older than 60 years
2. Any age with underlying health conditions like lung and heart disease, diabetes or conditions that affect the immune system
3. Complicated pregnancy
4. Children who are medically complex, who have neurologic, genetic, metabolic conditions or who have congenital heart disease.
It was also mentioned that in general COViD-19 is less severe in children because of prevention of virus exposure. Children are usually at home and on 24 hours curfew. Also, children have trained immunity, high ACE-2 expression metabolizing Angiotensin 2, absence of ageing related comorbidities, less degree of obesity, non smokers and they have healthier condition of their endothelium.
Covid-19 infection could range from being asymptomatic to mild, moderate, severe and critical. We should follow strictly the wearing of face mask, physical distancing and handwashing to make us win against our unseen enemy, the Covid-19.
Crowns for Kids
(Part 4)
This week, we will be discussing another facet of having dental crowns for kids.
Extensive tooth damage and preservation of the primary tooth are needed to ensure normal occulsion.
The desire to have nicer looking tooth is one among the goals for anterior crown.
Multisurface caries and cavities and enamel and imperfections of the tooth are indications that will need the use for crowns.
Dentists are usually doing the strip crown technique where.
a.) the dentist will determine if the case will need a crown.
b.) the dentist will select the right crown
c.) the dentist will prepare the tooth for crown installation
d.) reduction of interproximal surfaces and the reduction of incisal edge by approximately 1 mm.
e.) rouding out of the tooth edges
f.) placement of a small cervical undercut the gingival of the labial surface for mechanical retention.
g.) removal of caries with a spoon-shaped excavator or round bur
Dentists are also going to be doing adjusting fitting of the crown. This is being done to bring the crown to the desired size or even shape.
The dentist will also clean the tooth with the use of phosphoric acid, rinse, and dry. The dentist will be using a bonding agent and cure it for 10 seconds.
The crown is filled with composite resin, ensuring that the resin is squeezed into all the nooks and crannies. Then, the resin should be hollowed out in the center to reduce the excess amount composite material.
The dentist will fill the preformed crown with the correct shade of composite material and adapt the crown firmly on the subject tooth. It is important that the crown fits firmly with the tooth.
In turn, the composite material should be removed with a scalpel carefully. Then finally, the dentist will be checking the occulsion as a finishing touch.