Repeat kidney biopsies may help manage lupus nephritis flares
Click Here to Manage Email Alerts
Key takeaways:
- Overall, 56% of participants had a lupus nephritis class change on repeat biopsy.
- Of patients with initial proliferative classes, 51% had no class change.
Repeat kidney biopsies may help patients with lupus nephritis manage disease flares, particularly those who transition between proliferative and non-proliferative disease classes, data from a racially diverse study cohort show.
“The role of repeat kidney biopsies to manage flares of lupus nephritis has been studied in various populations but remains controversial,” Anitha Ramu, MD, a rheumatologist at the Montefiore Medical Center, wrote with colleagues. “In previous studies, Black and Hispanic patients were underrepresented, yet these racial and ethnic minority groups are disproportionately affected by lupus nephritis.”
Researchers collected clinical and pathology data from 55 adult and pediatric patients with lupus nephritis at Montefiore Medical Center and Jacobi Medical Center in Bronx, New York, between 2000 and 2020. Overall, 82% of participants were women, 51% were Black, 47% were Hispanic and 2% were Asian, and median ages at index and repeat biopsies were 25 years and 27 years, respectively.
Patients were diagnosed with lupus nephritis based on two or more biopsies using the International Society of Nephrology/Renal Pathology Society 2003 classification.
Indications for repeat biopsies were recurrent proteinuria following immunosuppression induction, worsening kidney function or no response to standard immunosuppression.
The time between index and repeat biopsy was 3 years.
Most biopsies showed proliferative lupus nephritis (classes III, IV, III+V, IV+V), including 64% of index biopsies and 75% repeat biopsies. A total of 25% or participants had induction therapy with cyclophosphamide, mycophenolate mofetil or azathioprine, while 16% did not receive immunotherapy due to non-proliferative disease classes (I, II or V), and 16% were unable to adhere to therapy.
Upon review, investigators found just more than half of participants (56%) had a lupus nephritis class change on repeat biopsy. Of participants with initial proliferative classes, 51% showed no class change, while 32% transitioned to a different class within the same proliferative category.
In addition, 6% shifted to class V, 3% to class II and 6% to a no lupus nephritis classification, defined by lupus podocytopathy and/or focal segmental glomerulosclerosis.
Investigators found 75% of participants with combined III and V or IV and V classifications remained histologically unchanged on repeat biopsies.
Ramu and colleagues also noted that within the initial proliferative category, 69% of participants had an escalation in disease class, 23% had a de-escalation and 9% did not have a class change. Among participants initially classified with non-proliferative disease, 60% transitioned to a proliferative class on repeat biopsy, leading to an escalation in disease class for 80% of participants.
In all, 73% of participants required treatment escalation, 20% had a de-escalation and 7% showed no change. Of those who required treatment escalation, 73% had a class change, while 27% did not change class but were deemed unresponsive to initial therapy, relapsed or switched medications. Most who had de-escalation (64%) did not have a class change but exhibited increased chronicity, recurrent infections or no lupus nephritis pathology.
“Our study of a minority racial and ethnic population showed that the majority (56%) of patients had a class change on repeat biopsy resulting in treatment change in 87% of cases,” the researchers wrote. “Our findings may aid in risk-to-benefit discussions about repeat biopsies in patients [with lupus nephritis].”
Collapse
Click Here to Manage Email Alerts