UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Indications for renal biopsy in patients with lupus nephritis

Authors
Ronald J Falk, MD
Maria Dall'Era, MD
Gerald B Appel, MD
Section Editors
Richard J Glassock, MD, MACP
Brad H Rovin, MD
Deputy Editor
Albert Q Lam, MD

INTRODUCTION

Renal involvement occurs in approximately 60 percent of patients with systemic lupus erythematosus (SLE) and is a major source of morbidity [1]. There are multiple histologic subtypes of lupus nephritis (LN), and the optimal treatment varies with the subtype [2]. Although the clinical presentation, urinalysis, and estimates of renal function may suggest a specific subtype, renal biopsy is necessary to confirm the correct classification category or class.

The indications for renal biopsy among patients already diagnosed with SLE will be reviewed here. The various types and classifications of lupus nephritis, their treatment, and the management of patients with end-stage renal disease (ESRD) are discussed separately. (See "Diagnosis and classification of renal disease in systemic lupus erythematosus" and "Therapy of diffuse or focal proliferative lupus nephritis" and "Clinical features and therapy of lupus membranous nephropathy" and "End-stage renal disease due to lupus nephritis".)

CLASSIFICATION AND CLINICAL PRESENTATION

The International Society of Nephrology (ISN) pathologic classification scheme for lupus nephritis (LN) is discussed in detail separately but will be reviewed here. The ISN classification, which is widely used, is a modification of an older system that was developed by the World Health Organization (WHO). (See "Diagnosis and classification of renal disease in systemic lupus erythematosus", section on 'Classification'.)

The ISN classification divides the glomerular disorders of lupus into six different, main classes or patterns, with subcategorizations based upon activity and chronicity of the lesions by light microscopy [3]. Although these disorders tend to have distinct histologic, clinical, and prognostic characteristics, there is substantial overlap among the classes, based in part upon variations in sampling. In addition, a significant percentage of patients evolve from one form to another, either spontaneously or after therapy. In one older series, for example, the probability of a transition from membranous to combined membranous and proliferative LN was 35 percent at 10 years [4]. This observation is not surprising, since the different histologic types of LN represent nonspecific responses to immune complex deposition. (See "Clinical features and therapy of lupus membranous nephropathy", section on 'Prognosis'.)

Minimal mesangial LN (class I) — Minimal mesangial LN is the earliest and mildest form of glomerular involvement. The glomeruli are normal by light microscopy, but immunofluorescence and electron microscopy reveal mesangial immune deposits. Affected patients typically have a normal urinalysis and serum creatinine concentration. As a result, renal biopsy is generally not performed, and the diagnosis is not often established.

             

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Tue Oct 06 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Beck LH Jr, Salant DJ. Treatment of membranous lupus nephritis: where are we now? J Am Soc Nephrol 2009; 20:690.
  2. Bomback AS, Appel GB. Updates on the treatment of lupus nephritis. J Am Soc Nephrol 2010; 21:2028.
  3. Weening JJ, D'Agati VD, Schwartz MM, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004; 15:241.
  4. Mercadal L, Montcel ST, Nochy D, et al. Factors affecting outcome and prognosis in membranous lupus nephropathy. Nephrol Dial Transplant 2002; 17:1771.
  5. Baranowska-Daca E, Choi YJ, Barrios R, et al. Nonlupus nephritides in patients with systemic lupus erythematosus: a comprehensive clinicopathologic study and review of the literature. Hum Pathol 2001; 32:1125.
  6. Ponticelli C, Moroni G. Renal biopsy in lupus nephritis--what for, when and how often? Nephrol Dial Transplant 1998; 13:2452.
  7. Mittal B, Rennke H, Singh AK. The role of kidney biopsy in the management of lupus nephritis. Curr Opin Nephrol Hypertens 2005; 14:1.
  8. Jennette JC, Iskandar SS, Dalldorf FG. Pathologic differentiation between lupus and nonlupus membranous glomerulopathy. Kidney Int 1983; 24:377.
  9. Adu D, Williams DG, Taube D, et al. Late onset systemic lupus erythematosus and lupus-like disease in patients with apparent idiopathic glomerulonephritis. Q J Med 1983; 52:471.
  10. Christopher-Stine L, Siedner M, Lin J, et al. Renal biopsy in lupus patients with low levels of proteinuria. J Rheumatol 2007; 34:332.
  11. Hahn BH, McMahon MA, Wilkinson A, et al. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken) 2012; 64:797.
  12. Faurschou M, Starklint H, Halberg P, Jacobsen S. Prognostic factors in lupus nephritis: diagnostic and therapeutic delay increases the risk of terminal renal failure. J Rheumatol 2006; 33:1563.
  13. Esdaile JM, Joseph L, MacKenzie T, et al. The benefit of early treatment with immunosuppressive agents in lupus nephritis. J Rheumatol 1994; 21:2046.
  14. Contreras G, Pardo V, Cely C, et al. Factors associated with poor outcomes in patients with lupus nephritis. Lupus 2005; 14:890.
  15. Huong DL, Papo T, Beaufils H, et al. Renal involvement in systemic lupus erythematosus. A study of 180 patients from a single center. Medicine (Baltimore) 1999; 78:148.
  16. Moroni G, Pasquali S, Quaglini S, et al. Clinical and prognostic value of serial renal biopsies in lupus nephritis. Am J Kidney Dis 1999; 34:530.
  17. Bajaj S, Albert L, Gladman DD, et al. Serial renal biopsy in systemic lupus erythematosus. J Rheumatol 2000; 27:2822.
  18. Austin HA 3rd, Illei GG, Braun MJ, Balow JE. Randomized, controlled trial of prednisone, cyclophosphamide, and cyclosporine in lupus membranous nephropathy. J Am Soc Nephrol 2009; 20:901.