Kidney Biopsy in Lupus Nephritis

“Repeat renal biopsy can help us identify complete remission more reliably,” explained Dr. Appenzeller. Because the optimal duration of maintenance immunosuppressive therapy for lupus nephritis is not clear, kidney biopsy can be an important tool in deciding whether to continue therapy. Biopsy helps clinicians balance the risks of ongoing immunosuppression vs. the risks of flare, which further increase the risks of chronic and end-stage kidney disease.¹⁰

Dr. Appenzeller discussed one prospective study of 75 patients during the maintenance phase of treatment for lupus nephritis. Roughly one-third of patients had histologic disease activity even though they had been in clinical remission for at least 12 months. The researchers continued maintenance immunosuppression in these patients, but allowed those with both ongoing clinical remission and histologic remission to stop their immunosuppression therapy. This approach seemed to decrease flare rates (1.5/year) compared with standard rates in the literature.¹⁰

Dr. Appenzeller also shared some complementary findings of a study showing histologic changes in repeated renal biopsies at diagnosis and consequent treatment of lupus nephritis. Higher inflammatorytype lesions—characterized by neutrophils, fibrinoid necrosis and cellular crescents—usually resolve completely during initial immunosuppression, she said. Standard-of-care treatment, including high-dose glucocorticoids, tends to work well for patients with such lesions.¹¹

However, other lesions tend to persist with standard-of-care therapy, although at lower levels, in 50–60% of patients after eight to nine months of treatment. Many patients had other histological lesions even longer, especially hyaline deposits, glomerular crescents and tubulointerstitial inflammation. Such lesions often appear to take months or years to resolve, supporting the current use of long-term maintenance therapy in many patients.¹¹

Ruth Jessen Hickman, MD, a graduate of the Indiana University School of Medicine, is a medical and science writer in Bloomington, Ind.

References

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