Systemic lupus erythematosus. Treatment-related complications superimposed on chronic disease

SELECTED CASE A 40-YEAR-OLD black woman with systemic lupus erythematosus (SLE) has been followed up in the arthritis clinic at the National Institutes of Health Clinical Center throughout most of the 19 years of her illness. The initial manifestations of her illness developed in the postpartum period of a pregnancy that had been complicated by proteinuria believed to be caused by toxemia. Proteinuria (2.8 g/24 h) accompanied by hematuria and red blood cell casts prompted a renal biopsy that revealed diffuse, proliferative glomerulonephritis (activity index, 6; chronicity index, 0). Other manifestations of her disease included polyarthralgias; erythematous rashes of the face, arms, and legs; and alopecia. Laboratory studies disclosed the following values: serum creatinine, 70 μmol/L; creatinine clearance, 1.75 mL/s; antinuclear antibody, 1:1280 (rim pattern); antibodies to DNA, 98% (Farr assay); and C3, 0.77 g/L. A daily 60-mg dose of prednisone was started, and during the next 2 years the