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Indications for renal biopsy in patients with lupus nephritis

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


Clinical 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 [1,2]. 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 LN, 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 "Treatment and prognosis 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".)


The International Society of Nephrology (ISN)/Renal Pathology Society (RPS) pathologic classification scheme for LN is discussed in detail separately but will be reviewed here. The ISN/RPS 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 pathology 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 subtypes 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.

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Literature review current through: Dec 2017. | This topic last updated: Jul 03, 2017.
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