Indian Journal of Rheumatology

EDITORIAL
Year
: 2017  |  Volume : 12  |  Issue : 1  |  Page : 4--5

Do we need renal biopsy in patients with lupus nephritis? A rheumatologist's perspective


Gurmeet Singh 
 Department of Medicine, Government Medical College, Jammu, Jammu and Kashmir, India

Correspondence Address:
Gurmeet Singh
Department of Medicine, Government Medical College, Jammu, Jammu and Kashmir
India




How to cite this article:
Singh G. Do we need renal biopsy in patients with lupus nephritis? A rheumatologist's perspective.Indian J Rheumatol 2017;12:4-5


How to cite this URL:
Singh G. Do we need renal biopsy in patients with lupus nephritis? A rheumatologist's perspective. Indian J Rheumatol [serial online] 2017 [cited 2017 Jul 20 ];12:4-5
Available from: http://www.indianjrheumatol.com/text.asp?2017/12/1/4/199577


Full Text

Renal involvement is seen in about half the patients of systemic lupus erythematosus (SLE) and may be as high as 75% of patients of African-American, Asians, and Hispanic ancestry. Around 20%–40% of the patients may have lupus nephritis (LN) at presentation itself.[1],[2] The severity of LN is not same in all the SLE patients and flares are common in individual patient with LN. LN is one of the most important predictors of outcome in SLE patients. Patients with LN tend to have worse outcomes as compared to patients without renal involvement. Patients with LN also have poor quality of life as compared to patients without LN.[2]

Renal biopsy is an invasive procedure associated with apprehension, pain, morbidity and rarely mortality. Whether renal biopsy needs to be done in patients with LN has been a widely debated topic. Researchers have tried to predict the histological picture of the LN by looking at the clinical picture along with serological markers such as anti-double-stranded DNA (dsDNA) and complement levels. Previous studies have shown that there is a discrepancy between the clinico-serological picture and histological findings. A study from Japan revealed that the frequency of LN other than Class I was found in 58% of the patients without clinical renal involvement. Class III and IV LN was found in 15% of these patients.[3] Similar findings may be observed for different classes of LN on histology and immunotherapy may need to be intensified in view of biopsy findings in these patients.[4] Even in patients with proteinuria of <1000 mg/day, the biopsy may reveal Class III, IV, or V LN.[5] Besides LN, patients of SLE may have nonlupus causes of renal involvement in the form of minimal change disease, focal segmental glomerulosclerosis, amyloidosis, IgA and IgM nephropathy or podocytopathies.[6],[7] The management of these conditions is different than what is required in LN.

The established indications renal kidney biopsy in SLE are proteinuria >500 mg/24 h, hematuria or active urinary sediment/cell casts with any level of proteinuria and acute rise in serum creatinine.[8] In this issue of the journal, Chelliah et al have reported their findings from a study in which they preformed renal biopsy in fifty patients of SLE with LN and tried to correlate clinico-serological findings with the histology findings of biopsy.[9] Although they found that combination of anti-dsDNA positivity, low C3, and low C4 had 100% positive predictive value for proliferative LN, only 28 of their 39 patients with proliferative LN had the combination of anti-dsDNA positivity, low C3, and low C4 levels. This provides a sensitivity of only 72%. Thus, 11 (28%) patients with proliferative LN were missed using this method; this is a high number. This again strengthens the argument that as far as possible renal biopsy needs to be done when it is indicated. The jury is still out whether follow-up renal biopsies are required in the patients with LN, but most of the nephrologist and rheumatologists are of the opinion that patients with LN need renal biopsy before starting on immunosuppressive therapy.[6],[10],[11]

All the rheumatologists may not be comfortable doing renal biopsy on their own, but most of the rheumatologist will have their nephrologists colleagues around ready to help them when the need arises. Many a times, renal biopsy is avoided in LN patients for varied reasons. Reluctance on the part of patients who may have minimal symptoms because of LN makes the task of convincing the patients for invasive proceedure may be difficult for the treating physicians. Patients may be more concerned about the symptoms like malar rash or polyarthritis, which are visible and causing them distress.

Some rheumatologists may not have access to the facilities for the biopsy or may not have a nephrology colleague in the immediate area of their practice. With patients not willing to travel to a center where the biopsy facility is available, the treatment may have to be started without biopsy. Even when biopsy is done the question arises whether there is an expert renal pathologist available to have a look at the biopsy specimens. In addition, the facilities for immunofluorescent microscopy may not be available at smaller centers. This issue may have been taken care of by some private laboratories which collect samples from their franchisees and sends them to a central location for processing. There might be a feeling among the treating physician of a possibility of losing a patient to the nephrologist if the patient is referred for renal biopsy, but most of the times the patient comes back to the treating physician and the management of the patient is usually a shared venture.

Most of the guidelines or recommendations for the management of LN have been developed in the developed world and may have not taken into account the prevailing socioeconomic situation of the resource poor countries.[8],[10],[11] It is not uncommon to see therapy for LN started before kidney biopsy because of above mentioned reasons. In patients of LN with rapidly deterioration renal function, the kidney biopsy is sometimes done after starting the immunosuppressive treatment. Kidney biopsy is an intervention which is likely to help in the better management of the SLE patient with LN and needs to be done as and when indicated.

References

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