Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Rapid renal or pulmonary deterioration
Oliguria, rapidly rising creatinine, severe hypertension, hyperkalaemia, pulmonary oedema, pulmonary haemorrhage or thrombotic microangiopathy requires emergency renal and rheumatology assessment.
Action: Stabilise airway, breathing, circulation, potassium and fluid complications; obtain cultures and haemolysis studies, exclude thrombosis and obstruction, and arrange urgent nephrology-rheumatology treatment without waiting for routine clinic review.
Synopsis
Detect renal involvement early in systemic lupus erythematosus, integrate biopsy class with whole-patient activity, coordinate contemporary induction and maintenance, and protect kidneys through adherence, pregnancy planning and complication surveillance.
Screen every person with SLE using blood pressure, creatinine, urinalysis and quantitative protein when abnormal; absence of oedema or urinary symptoms does not exclude nephritis.
New proteinuria, glomerular blood, casts or unexplained renal decline warrants urgent combined nephrology-rheumatology review and timely kidney biopsy when safe.
Anti-dsDNA rise and C3 or C4 fall can support immunological activity but do not prove a renal flare, determine histological class or exclude infection.
Key red flags
New glomerular haematuria, casts, rising proteinuria or kidney dysfunction in SLE needs urgent combined renal and rheumatology assessment even without oedema.
Pulmonary-renal emergency
Haemoptysis, anaemia, hypoxia and diffuse infiltrates with active urine may represent pulmonary haemorrhage and requires immediate multidisciplinary treatment.
Investigation priorities
01
Urinalysis, microscopy, ACR and PCRFirst step
Identify glomerular inflammation and quantify albumin and total protein using repeatable measures.
Management branches
First-line renal detectionQuantify, triage and biopsy
SLE review identifies new protein, glomerular blood, hypertension or declining renal function.
Repeat a clean urine sample, quantify ACR or PCR, examine sediment, trend creatinine and pressure and assess fluid, thrombosis, infection and extra-renal activity.
Send complement, anti-dsDNA, blood count, haemolysis and targeted cultures while treating hyperkalaemia, pulmonary oedema, severe hypertension or sepsis immediately.
Preferred proliferative inductionCombine early and taper steroids
Biopsy shows active class III or IV nephritis, with or without class V, and meaningful reversibility.
Key medicines
Mycophenolate mofetilSpecialist induction commonly starts at 500 mg orally twice daily and increases as tolerated to 1–1.5 g twice daily; maintenance often uses 500 mg–1 g twice daily according to response, toxicity and the protocol.
Reduced-dose glucocorticoid inductionFor active proliferative disease, specialists may give intravenous methylprednisolone 250–1,000 mg daily for one to three doses, then oral prednisolone no more than about 0.5 mg/kg/day with a protocolised taper toward 5 mg/day by six months when response permits.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.