P0639 - Diabetic Nephropathy and End-Stage Renal Disease in a 28 year old, or Is It?

Introduction: Systemic Lupus Erythematosus (SLE) is an auto-immune disease which affects multiple organ systems. Concomitant chronic inflammatory conditions can worsen disease prognosis. The addition of psycho-social barriers makes diagnosis and treatment more difficult. This case will emphasize the importance of holistic patient care.

Case Description: A 28-year-old Hispanic female with end-stage renal disease on hemodialysis for 2 years, Type 1 diabetes mellitus since age 10 years old, hypothyroidism secondary to Hashimoto’s, and four miscarriages was admitted to the ICU with pneumonia, pleural effusions, and reduced ejection fraction heart failure. Further detailed history revealed sun-sensitivity and a recent episode of arthritis. Considering her unstable condition, multiple auto-immune conditions, and rapidly progressing renal disease, work-up for other underlying diseases was prompted. Lab tests revealed an elevated ANA and positive anti-body titers. Follow-up with out-patient Rheumatology led to a diagnosis of SLE with overlap syndrome.

Discussion: SLE patients present with a wide variation in signs and symptoms, requiring thorough history and physical examination. As with our patient, who presented with a history of hypothyroidism and Type 1 Diabetes Mellitus, it is not uncommon for patients with SLE to have other auto-immune disorders. Co-presentation of T1DM and SLE is not common, as one study showed only 3 such cases out of 485 lupus patients with co-existing auto-immune conditions. However, renal and cardiovascular complications were increased two-fold in these patients. It is therefore important to carefully evaluate new symptoms and signs with laboratory work-up and outpatient follow-up in patients with auto-immune disorders.
Research regarding ethnographic and psycho-social impacts on SLE is lacking, and the little that has been done points to greater severity of disease progression in certain demographic groups. Compared to non-Hispanic white women (64.3 per 100,000), who are more readily included in research studies, prevalence of SLE in Hispanic women is 138.3 per 100,000. In one study, it was found that the DNA methylation in patients with SLE are ethnicity-dependent and can determine the disease course. 49.4 percent of Hispanic patients present with renal manifestations, in contrast to 25.4 percent of Caucasians. There is a greater mortality rate, ranked as the fifth and sixth leading cause of death among ages 15-24 years and 25-34 years respectively, earlier presentation, and more severe disease course in the Hispanic population.

Conclusion: The distinction between ethnicities cannot be adequately made with the current selection of research studies. Until SLE in different ethnographic populations is better understood, healthcare professionals must be aware of the importance of a thorough patient-centered diagnosis and treatment plan, especially when a woman of color presents with multiple auto-immune conditions and new symptoms. Understanding the holistic approach and long-term health management is important in better treatment for patients with SLE and co-morbid auto-immune diseases.