Kidney biopsy–based management of maintenance immunosuppression is safe and may ameliorate flare rate in lupus nephritis

Malvar, Ana; Albertón, Valeria; Lococo, Bruno; Ferrari, Matías; Delgado, Pamela; Nagaraja, Haikady N.; Rovin, Brad H.

doi:10.1016/j.kint.2019.07.018

Cited by 90 publications

(76 citation statements)

References 18 publications

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“…Two recent prospective observational cohort studies exploring the value of repeat biopsies in guiding maintenance immunosuppression in patients with proliferative LN reported virtually no biopsy-related complication. 28,29 EULAR/ERA-EDTA and ACR guidelines both recommend major immunosuppressive agents (e.g., cyclophosphamide, mycophenolate mofetil) for proliferative or mixed proliferative and membranous LN, whereas for class V with subnephrotic proteinuria, the recommendation is to treat with renin-angiotensinaldosterone system inhibitors and monitor closely. Because the patients included in our and similar studies have been for the most part treated according to the histological diagnosis, we do not have a sense of how the clinical course would have been without treatment.…”

Section: Discussionmentioning

confidence: 99%

Low-Level Proteinuria in Systemic Lupus Erythematosus

Chedid

Rossi

Peyronel

et al. 2020

Kidney International Reports

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Introduction: In patients with systemic lupus erythematosus (SLE) without concurrent active urinary sediment or unexplained acute kidney injury (AKI), current guidelines recommend performing a kidney biopsy in those with at least 500 mg/24-hour (European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association [EULAR/ERA-EDTA]) or 1000 mg/24-hour (American College of Rheumatology [ACR]) proteinuria. To evaluate the relevance of these indications, we studied histopathologic findings in patients with SLE with proteinuria below these cutoffs. Methods: We retrospectively reviewed the clinical, laboratory and histological characteristics of patients with SLE with <1000 mg/24-hour proteinuria (or mg/g urinary protein-to-creatinine ratio [UPCR]) who underwent their first kidney biopsy between 2003 and 2018. Results: We identified 87 patients with SLE with proteinuria less than 1000 mg/24-hour (or mg/g UPCR); 52 of 87 (60%) with isolated proteinuria, that is, without AKI or active urinary sediment (hematuria). Histologic evidence of lupus nephritis (LN) was present in 40 of 52 (76%). Of the 40 patients with LN, 12 had class I or II, 14 had class III or IV, 8 had class V, 6 had a combined proliferative and membranous LN. Non-lupus diagnoses included focal segmental glomerulosclerosis, acute interstitial nephritis, and others. Patient's age, low C3, low C4, and positivity for anti-double-stranded DNA (anti-dsDNA) antibodies predicted the histological diagnosis of LN on univariate logistic regression; however, a multivariate model including these parameters as independent covariates failed to predict LN. Conclusions: Patients with SLE with low-level proteinuria may have significant lupus-or non-lupus-related kidney disease with management implications. There was a significant burden of severe forms of LN. The presence of LN was not predicted by laboratory abnormalities. Based on our findings, we suggest current guidelines be revised to expand kidney biopsy indications to include isolated proteinuria of any grade.

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Section: Discussionmentioning

confidence: 99%

Low-Level Proteinuria in Systemic Lupus Erythematosus

Chedid

Rossi

Peyronel

et al. 2020

Kidney International Reports

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“…Protocol biopsies were recently used in a LN cohort to decide whether to discontinue maintenance therapy. 57 Patients were only weaned off therapy if no histologic activity was found; a low flare rate and low rate of renal -biopsy related complications suggest this strategy may be appropriate in this scenario.…”

Section: Relapse Risk Factors and Identificationmentioning

confidence: 99%

Treatment of lupus nephritis – past, present and (near) future

Navarro

2020

pjnh

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Lupus nephritis is one of the best-studied SLE complications. The reasons are twofold: 1) the morbidity and mortality are increased in SLE patients with renal involvement; 2) kidney biopsies, as opposed to serum autoantibodies, allow for direct visualization of active and chronic damage to tissues. It is thus no surprise that a histomorphological classification emerged in 1964 3 , based solely on light microscopy. This first attempt classified patients into 3 groups: lupus glomerulitis; active lupus glomerulonephritis and membranous lupus glomerulonephritis. Few changes were made until the 2004 joint World Health Organization and ISN/RPS (International Society of Nephrology / Renal Pathology Society) classification, which is still used to this date (Table 1).

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“…Melva Louisa, 5 Andi Yasmon, 6 Susan Rahayu. 1 Allergy and Clinical Immunology Division, Dept. of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta; 2 Dr. Cipto Mangunkusumo National General Hospital, Jakarta; 3 Doctoral Program in Biomedical Science, Faculty of Medicine, Universitas Indonesia, Jakarta; 4 Dept.…”

Section: O3mentioning

confidence: 99%