Hypertension and Its Complications in a Young Man With Autoimmune Disease

A 30-year-old man, who had moved to the United Kingdom from South Asia, was referred to the renal clinic with nephrotic syndrome. He had recently been diagnosed with systemic lupus erythematosus (SLE) after presenting to the rheumatology clinic with joint pain, skin rash, and pleuritic chest pain and fulfilling 8 of 17 SLICC (Systemic Lupus International Collaborating Clinics) diagnostic criteria.1 His immunology was in keeping with active SLE: his complement levels were low, and he had antibodies against double-stranded DNA and extractable nuclear antigens (Table S1A in the online-only Data Supplement). Our patient had heavy proteinuria (3.9 g/d) and a low serum albumin (25 g/L) in keeping with the nephrotic syndrome. Although his excretory renal function was normal, he had microhematuria (3+) on urinalysis. An urgent renal tract ultrasound with Doppler revealed that he had a preexistent renal vein thrombosis for which he was anticoagulated. In the absence of any serological evidence of antiphospholipid syndrome, this was attributed to his nephrotic syndrome. He went on to have a renal biopsy. This demonstrated classes III (focal proliferative) and V (membranous) lupus nephritis (Figure 1). Figure 1. Initial glomerular histology. A , Normal glomerulus. Single arrow: Normal capillary wall. This should be a similar thickness to the tubular epithelium (arrowhead). Double arrow: Normal mesangium. B , Classes III (focal proliferative) and V (membranous) lupus nephritis. Single arrow: Thickened capillary wall. Double arrow: Focal proliferation. At presentation, his blood pressure (BP) was 126/88 mm Hg in the absence of antihypertensive treatment. Although this lay within both UK and US recommended guidelines, …