Thanks a lot for the opportunity and, more importantly, an impetus to keep moving. Hope you all stayed engaged and entertained See you in other @ECNeph discussions. #ECNeph

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores Diagnoses in nephrology at different junctures Few at admission Few in the history Few in the sequence Few in the investigations Few in the biopsy And a few in the recovery

#ECNeph @brammahin.@myadla. @Dilushiwijay @dra_miliflore @acssjr Similar presentation in Post Tx Pt But ..why is it so rare ? Why dont we see it often despite high use ? Thoughts ?

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores pubmed.ncbi.nlm.nih.... pubmed.ncbi.nlm.nih....#ECNeph ☄️ More than few reported cases exist

When you suspect MMF-hyperinflammation dont forget to exclude these #ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores @acssjr.bsky.social

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores ⚠️ Few warnings exist already

Proposed mechanism of hyperinflammation due to MMF #ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores @acssjr.bsky.social

💥 Could this be MAS in SLE? We are seeing it more often, 🗝️ - Clues in clinical practice Fever Pancytopenia Organomegaly ⬇️ ESR with disease activity #ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

Differentiating fever from flare in lupus #ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores @acssjr NLR CRP/ESR ratio <2/2-15/>15 : <2 s/o infection

#ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores 💣. Predisposition - Yes Not enough for diagnosis ❌ No organism identified ❌ No focus of infection

ℹ️Turns out patient has hypogammaglobulinemia ❓MMF related/disease related Ig A - 134 mg/dl ( 70-400) ⬇️Ig G - 669 mg/dL (700-1600) ⬇️⬇️Ig M - 38 mg/dL (40-230) 😏Does it explain all? #ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores #ECNeph Do you agree ? Post your final diagnosis .... Is it to do with IST ?

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores #ECNeph see the time line of admissions for febrile episodes Class switch High inflammatory markers Infection clues negative 3 episodes in 2-3 months Where should this lead to ?

🦠 When do you think fever is of infection in origin? ⁉️ Can we rule out all infections all the times? Say some hidden TB or a very timid virus. We need more markers. #ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores #ECNeph yet another admission ..in a weeks time premature discharge vs recurrence of infection /appearance of flare High inflammatory markers favour infection or is it non infectious inflammation

⚓️ What features would suggest SLE activity for you? ⚖️ Do you weigh on global assessment? #ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores #ECNeph Rx with antibiotics Restarted on IST after fever subsidence What next ? Evaluation being negative for all infections : Bacteria /virus .. How to go further ?

🔂 3 admissions with acute febrile illnesses within 2-month span 🩺 No focal signs/symptoms ☢️ Routine imaging -negative -No organ-specific illness #ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

#ECNeph @brammahin @myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores ESR:CRP <2 S/O infection than flare Lupus. 2018 Jun;27(7):1123-1129

How to differentiate between flare /Infection in SLE #ECNeph @brammahin @myadla @Dilushiwijay @dra_miliflores @acssjr.bsky.social

🗣️Fever in SLE - An enigma wrapped in mystery. Interested in hearing your phrases of fever and also how do you define it in routine practice? 🧈 Just basics #ECNeph @brammahin @Dilushiwijay @myadla @acssjr @dra_miliflores

#ECNeph @brammahin @myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores Does the evaluation suggest flare ? All atypical infections ruled out Malignancy ?????? What else ? PET-CT ?

#ECNeph@brammahin@myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores How to differentiate flare /infection in SLE Infection versus disease activity in systemic lupus erythematosus patients with fever. BMC Rheumatol. 2024 Aug 14;8(1):34

#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr @dra_miliflores Admitted in a weeks time with fever , polyarthralgia Is it relapse /recurrence of infection High inflammatory markers : is it SLE flare ?

#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr@dra_miliflores Febrile admission in year time Flare vs infection ? Rx : Antibiotics ..Response + Whats the time of reinitiation of IST after infection ?

How to differeentiate flare from infection ? Any novel markers #ECNeph

#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr@dra_miliflores Admitted with Febrile illness - Pneumonia Appropriate antibiotics given

#ECNeph@brammahin@myadla@ISNkidneycare@Dilushiwijay@acssjr@dra_miliflores Now Pt on triple IST with MMF /HCQ CyC not initiated -Young woman Proteinuria remission attained

#ECNeph @brammahin @myadla @ISNkidneycare @Dilushiwijay @acssjr @dra_miliflores Class switching in LN Bomback AS. Nonproliferative Forms of Lupus Nephritis: An Overview. Rheum Dis Clin North Am. 2018 Nov;44(4):561-569

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores @Dilushiwijay @ISNkidneycare Admitted with febrile illness Flare vs infection Any other DD ? Thoughts plz ! Mild rise in creatinine Kidney Bx : Now Class III LN

#ECNeph @brammahinv@myadla @Dilushiwijay @acssjr @dra_miliflores @Dilushiwijay @ISNkidneycare CNI based regimen started On HCQ Proteinuria remitting ... ...Non adherence

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores @Dilushiwijay @ISNkidneycare Recap of EULAR -ACR criteria

Welcome, Brammah! We are looking forward to learning today 🤓 #ECNeph #NephSky

#ECNeph @brammahin @myadla @dra_miliflores @acssjr @Dilushiwijay Lets check criteria of Lupus podocytopathy Lupus Podocytopathy: An Overview. Adv Chronic Kidney Dis. 2019 Sep;26(5):369-375

23 YO woman with lupus -recurrent admissions Here are more details ! #ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores @Dilushiwijay @theisn.org

#ECNeph @brammahin @myadla @Dilushiwijay @acssjr @dra_miliflores @Dilushiwijay @ISNkidneycare Is the diagnosis obvious ? Should we check labs? ANA+VE/low C3/hemat /Musculo skeletal involvement /Kidney Biopsy done in v/o proteinuria : Class 1 Can it be podocytopathy

#ECNeph Nephrologist fromSri Lanka and the Discussant for the day , one of the few!

# ECNeph @acssjr.bsky.social @myadla.bsky.social @dilushiwijay.bsky.social @theisn.org Its Brammah ,Discussant for the day,from the beautiful isle of Sri Lanka