Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with established Class VI Lupus Nephritis (ISN/RPS classification). History significant for long-standing SLE with progressive decline in eGFR. Current status reflects end-stage renal disease (ESRD) with >90% global glomerulosclerosis on prior biopsy. Patient is currently [asymptomatic / symptomatic for uremia], maintaining [conservative management / renal replacement therapy]. No active urinary sediment or evidence of acute inflammatory flare.
Clinical Examination Findings
General appearance: Chronically ill, pale, stable. Vital signs: BP [Value] mmHg (hypertensive), HR [Value] bpm. Skin: No active vasculitic rash or photosensitivity. Edema: [Grade 1-4] pitting edema noted in lower extremities. Hydration status: [Euvolemic/Hypervolemic].
Treatment Protocol
Immunosuppression for renal indications is discontinued due to irreversible sclerotic damage. Focus shifted to renoprotection, management of ESRD complications, and blood pressure control. Plan: [Initiate/Continue] ACEi/ARB for proteinuria reduction (if applicable), phosphate binders, vitamin D supplementation, and preparation for renal replacement therapy (hemodialysis/peritoneal dialysis/transplant evaluation).