The value of repeat biopsy in the management of lupus nephritis: an international multicentre study in a large cohort of patients

Pagni, Fabio; Galimberti, Stefania; Goffredo, Paolo; Basciu, Maria; Malachina, Sara; Pilla, Daniela; Galbiati, Eleonora; Ferrario, Franco

doi:10.1093/ndt/gft272

Cited by 56 publications

(43 citation statements)

References 23 publications

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“…As shown by other studies [8,9,22,23] , we found persistent histopathological renal activity despite apparent clinical response. Furthermore, PL in repeated RB was associated with more frequent and early risk of renal flare.…”

Section: Discussionsupporting

confidence: 89%

Repeated Renal Biopsy - A Predictive Tool to Assess the Probability of Renal Flare in Lupus Nephritis

Piñeiro

Arrizabalaga

Solé³

et al. 2016

Am J Nephrol

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Background: How one responds to treatment of lupus nephritis (LN) is based on clinical features, but the activity in renal biopsy (RB) is uncertain. We have described the therapeutic decisions after performing a repeated RB on the assessment of response to intravenous cyclophosphamide (IC) and the possible prognostic role of this repeated RB. Methods: Clinical, laboratory and histological features at the initial RB and repeated RB were analyzed in 35 patients. Results: Data in the initial versus the repeated RB were serum creatinine 1.23 ± 1.08 and 0.96 ± 0.45 mg/dl (p < 0.05), glomerular filtration rate <60 ml/min in 12 and 5% patients and proteinuria 4.1 ± 2.8 vs. 0.6 1.1 g/day (p < 0.05). Significant differences were detected in hematuria, nephrotic syndrome and serological immune features. Complete renal remission was reached in 60% (n = 21) at the time of the repeated RB, partial remission in 31.4% (n = 11), and no response IC in 8.6% (n = 3). Nine patients showed proliferative forms in the repeated RB, 3 of them had proteinuria <1 g/day. Just after the repeated RB, 34.3% increased or started a new immunosuppressive therapy, 17.1% remained with the same complementary IST, and 14.3% decreased or stopped it. In the follow-up post repeated RB, 34.5% without active lesions showed a renal flare versus 77.8% with active lesions (p = 0.04). The mean time was 120 and 45 months, respectively. Conclusion: A repeated biopsy in LN distinguishes patients in true remission from those in apparent remission. By doing this, we can identify patients who could benefit from intensified treatment and for whom unnecessary treatment methods can be modified or eliminated.

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Section: Discussionsupporting

confidence: 89%

Repeated Renal Biopsy - A Predictive Tool to Assess the Probability of Renal Flare in Lupus Nephritis

Piñeiro

Arrizabalaga

Solé³

et al. 2016

Am J Nephrol

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“…[1,3,5] However, data from the literature do not seem to confirm this approach. [4,68,70,71,74,75] Although the proliferative classes were the majority in the reference biopsy in nearly all of the reviewed series (484/676; 72%), the results of the repeat biopsy led to a change in the immunosuppressive treatment in 18% to 79% of the patients (mean 57% of cases), intensifying it in the majority of the cases (between 18% and 60.5%; mean 39%). These data suggest that in daily clinical practice, in some cases with clear progression of proliferative lesions in the second biopsy despite the initial treatment, the immunosuppressive treatment was intensified to avoid the progression of renal damage and the development of sclerosing lesions.…”

Section: Discussionmentioning

confidence: 99%

“…The results of our series, as well as the literature review, confirm that histological transformation is very prevalent during an LN flare, ranging from 40% to 76% of cases, [68–76] and supports the usefulness of a repeat biopsy in guiding treatment of LN flares, both to identify those patients for whom it is necessary to intensify immunosuppression therapy and to avoid unnecessary increased immunosuppression therapy in others. [4,68,70,71,73–75] However, the frequency of histological transformation and the clinical value of repeat biopsy vary greatly depending on the LN class from the initial biopsy.…”

Section: Discussionmentioning

confidence: 99%

The value of repeat biopsy in lupus nephritis flares

Narváez¹,

Ricse²,

Gomà³

et al. 2017

Medicine

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Whether a repeat renal biopsy is helpful during lupus nephritis (LN) flares remains debatable. In order to analyze the clinical utility of repeat renal biopsy in this complex situation, we retrospectively reviewed our series of 54 LN patients who had one or more repeat biopsies performed only on clinical indications. Additionally, we reviewed 686 well-documented similar cases previously reported (PubMed 1990–2015).The analysis of all patients reviewed showed that histological transformations are common during a LN flare, ranging from 40% to 76% of cases. However, the prevalence of transformations and the clinical value of repeat biopsy vary when they are analyzed according to proliferative or nonproliferative lesions.The great majority of patients with class II (78% in our series and 77.5% in the literature review) progressed to a higher grade of nephritis (classes III, IV, or V), resulting in worse renal prognosis. The frequency of pathological conversion in class V is lower (33% and 43%, respectively) but equally clinically relevant, since almost all cases switched to a proliferative class. Therefore, repeat biopsy is highly advisable in patients with nonproliferative LN at baseline biopsy, because these patients have a reasonable likelihood of switch to a proliferative LN that may require more aggressive immunosuppression.In contrast, the majority of patients (82% and 73%) with proliferative classes in the reference biopsy (III, IV or mixed III/IV + V), remained into proliferative classes on repeat biopsy. Although rebiopsy in this group does not seem as necessary, it is still advisable since it will allow us to identify the 18% to 20% of patients that switch to a nonproliferative class. In addition, consistent with the reported clinical experience, repeat biopsy might also be helpful to identify selected cases with clear progression of proliferative lesions despite the initial treatment, for whom it is advisable to intensify inmunosuppression. Thus, our experience and the literature data support that repeat biopsy also brings more advantges than threats in this group.The results of the repeat biopsy led to a change in the immunosuppresive treatment in more than half of the patients on average, intensifying it in the majority of the cases, but also reducing it in 5% to 30%.

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“…A high rate of transformations to another histological class was observed in reports in which a repeat biopsy was performed for various reasons [71,83], (Table 4). However, no clinical predictor of transformation has been identified [81,84].…”

Section: How Often Should Renal Biopsy Be Performed?mentioning

confidence: 95%