Original Investigation
Clinical and prognostic value of serial renal biopsies in lupus nephritis

https://doi.org/10.1016/S0272-6386(99)70082-XGet rights and content

Abstract

Little information is available about the role of repeated renal biopsies in lupus nephritis. We analyzed retrospectively the prognostic significance of serial renal biopsies in patients with lupus nephritis. Thirty-one patients with lupus nephritis underwent two or more renal biopsies during follow-up. The indications for repeated biopsy were as follows: improvement of renal disease but persistence of nonnephrotic proteinuria (group A, 7 patients); persistent or relapsing nephrotic syndrome (group B, 12 patients); and worsening of renal function (group C, 19 patients). After a median follow-up of 10.5 years, 17 patients reached the end point (persistent doubling of plasma creatinine level). At repeated renal biopsy, there was a correlation between improved clinical and histological features for group A. In these patients, treatment was reduced or stopped successfully. Histological features remained almost unchanged in group B. All patients showed an improvement of proteinuria after reinforcement of therapy. In group C, the worsening of renal function was associated with a variable and clinically unpredictable combination of active and chronic lesions. Only the few patients with an elevated activity index and moderate chronicity index showed a favorable and persistent improvement of renal disease after reinforcement of therapy. At multivariate analysis of clinical and histological data at presentation, only male sex was predictive of an adverse outcome (P = 0.015). At repeated renal biopsy, crescents in more than 30% of glomeruli (P = 0.0009) and chronicity index of 5 or greater (P = 0.00006) were associated with the probability of reaching the end point at multivariate analysis. Repeated renal biopsy may be helpful for establishing the prognosis in patients with lupus nephritis, particularly in the presence of worsening of renal function.

Section snippets

Methods

Thirty-one Italian patients with lupus nephritis followed up by two nephrology units (Ospedale Malpighi, Bologna; Ospedale Maggiore, Milano, Italy) between January 1965 and January 1997 participated on this study. The inclusion criteria were: (1) diagnosis of systemic lupus erythematosus according to the revised American Rheumatism Diagnostic Criteria,18 (2) urine protein excretion of more than 1 g/d and/or elevated plasma creatinine level at presentation, and (3) renal biopsy performed at the

Clinical characteristics at first renal biopsy

Of the 31 patients with lupus nephritis who entered onto the study, 26 were women and 5 were men. At admission, the median age was 23 years (25th and 75th percentile, 18 and 31), and the median duration of lupus nephritis was 3 months (25th and 75th percentile, 0 and 10.5). Fifteen patients had elevated plasma creatinine levels (median, 2.2 mg/dL; 25th and 75th percentile, 1.5 and 4.9), whereas the other 16 patients had a plasma creatinine level between 0.5 and 1.1 mg/dL. The median proteinuria

Discussion

There are few reports on serial renal biopsies in patients with lupus nephritis. Most of those studies showed a transformation from one histological class to another in 26% to 50% of repeated renal biopsy.13, 15, 17, 24, 25, 26, 27, 28 However, little attention was given to the prognostic significance of repeated biopsy. Balow et al29 evaluated the variations of chronicity index in patients assigned to different therapeutic regimens. Patients treated with prednisone alone showed a significant

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    Received December 28, 1998; accepted in revised form March 26, 1999.

    Address reprint requests to Gabriella Moroni, MD, Divisione di Nefrologia e Dialisi, Istituto Scientifico Ospedale Maggiore Policlinico, Via Commenda, 15, 20122 Milano, Italy. E-mail: [email protected]

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