Redefining When to Biopsy the Kidney in Patients with SLE

Michelle Petri¹, Andrea Fava², Mohamed Atta³, Avi Rosenberg³, Sanchit Sanyal³, Peter Izmirly⁴, Erin Carter⁵, Mala Masson⁶, Michael Belmont⁷, Jennifer Barnas⁸, Jennifer Anolik⁹, Brad Rovin¹⁰ and Jill Buyon⁴, ¹Johns Hopkins University School of Medicine, Timonium, MD, ²Johns Hopkins University, Baltimore, MD, ³Johns Hopkins University School of Medicine, Baltimore, MD, ⁴NYU Grossman School of Medicine, New York, NY, ⁵New York University Grossman School of Medicine, New York, NY, ⁶NYU Langone Medical Center- Division of Rheumatology, New York, NY, ⁷NYU Langone Health, New York, NY, ⁸University of Rochester, Rochester, NY, ⁹University of Rochester Medical Center, Rochester, NY, ¹⁰The Ohio State University, Columbus, OH

Meeting: ACR Convergence 2025

Keywords: Diagnostic criteria, Lupus nephritis, Systemic lupus erythematosus (SLE)

Session Information

Date: Sunday, October 26, 2025

Title: Plenary I (0772–0776)

Session Type: Plenary Session

Session Time: 9:45AM-10:00AM

Background/Purpose: Current ACR, EULAR and KDIGO guidelines recommend kidney biopsy in SLE patients with urine protein to creatinine (UPCR) ratio of >= 0.50 g/g. However, SLE patients who undergo kidney biopsy at lower levels of UPCR are frequently found to have proliferative lupus nephritis (Wang S, et al. Clin J Am Soc Nephrol. 2022;17:1150-1158). As part of the Accelerated Medicines Partnership we investigated first onset of UPCR 0.250-0.499 g/g.

Methods: SLE patients with no history of LN and UPCR of 0.250 to 0.499 g/g PLUS another predictor of lupus nephritis (LN) including non-White race, serologies (low C3, low C4, or anti-dsDNA). or active urine sediment, were enrolled. Kidney biopsies were done at the site institution and reported as ISN Class I-VI with NIH Activity and Chronicity Index, if LN.

Results: Twenty-eight patients were enrolled: 24 (86%) females, 6 (21%) Hispanic, and 13 (46%) African-American, 7 (25%) White, 2 (7%) Asian and 6 (21%) Other race. Twenty-five (89%) were anti-dsDNA positive, 20 (71%) had low C3 and 19 (68%) had low C4 at enrollment. All had GFR >60, no immunosuppression and prednisone < 10mg/day. Seven patients were taking ACEi/ARBs, two SGLT2 inhibitors (both were no LN on subsequent biopsy) and 23 hydroxychloroquine. Twenty had LN: two Class I; five Class II; six Class III; and seven Class V. Eight did not have LN (Table 3): 6 (75%) had a history of positive anti-dsDNA; 3 (38%) had a history of low C3; and 3 (38%) had a history of low C4. Table 1 shows the NIH Activity and Chronicity Indices, UPCR and serologies by ISN Class. There were no biopsy complications. Patients with LN were more likely to have had a history of low C3 (p=0.0223) or low C4 (p=0.0296) prior to enrollment (Table 2).In longitudinal follow up, two Class II, two Class III and three Class V have progressed to greater than 0.5 g/g of UPCR (in spite of treatment of Class III and Class V).

Conclusion: The 0.50 g/g UPCR cut-off for kidney biopsy in LN guidelines is arbitrary, omitting an opportunity to identify early LN before accrual of kidney damage. Earlier biopsy of LN, as defined by the AMP algorithm (UPCR between 0.250 and 0.499 g/g PLUS another LN predictor), found LN in 69%, with 61% initiating mycophenolate (6 Class III and 5 Class V) and 17% already showing some degree of chronicity. History of low C3 or C4 was the most important component of the AMP algorithm. The AMP early LN algorithm identified a high incidence of patients with consequential pathology and strongly support an adjustment to the UPCR cutoff for kidney biopsy in LN guidelines.

Table 1. Characteristics of lupus nephritis patients and biopsies

Table 2. Comparison of inclusion criteria between those with lupus nephritis vs those without lupus nephritis

Table 3. Histology of non-lupus nephritis biopsies

Disclosures: M. Petri: Amgen, 2, AnaptysBio, 2, Annexon Bio, 2, AstraZeneca, 2, 5, Atara Biosciences, 2, Aurinia, 2, 5, Autolus, 2, Bain Capital, 2, Baobab Therapeutics, 2, Biocryst, 2, Biogen, 2, Boxer Capital, 2, Cabaletto Bio, 2, Caribou Biosciences, 2, CTI Clinical Trial and Consulting Services, 2, CVS Health, 2, Dualitybio, 2, Eli Lilly, 2, 5, EMD Serono, 2, Emergent, 2, Escient Pharmaceuticals, 2, Exagen, 5, Exo Therapeutics, 2, Gentibio, 2, GlaxoSmithKlein(GSK), 2, 5, iCell Gene Therapeutics, 2, Innovaderm Research, 2, IQVIA, 2, Janssen, 5, Kezar Life Sciences, 2, Kira Pharmaceuticals, 2, Nexstone Immunology, 2, Nimbus Lakshmi, 2, Novartis, 2, Ono Pharma, 2, PPD Development, 2, Proviant, 2, Regeneron, 2, Seismic Therapeutic, 2, Senti Biosciences, 2, Sinomab Biosciences, 2, Steritas, 2, Takeda, 2, Tenet Medicines, 2, TG Therapeutics, 2, UCB, 2, Variant Bio, 2, Worldwide Clinical Trials, 2, Zydus, 2; A. Fava: Artiva, 2, AstraZeneca, 1, 2, Bain Capital, 2, Biogen, 1, Bristol-Myers Squibb(BMS), 2, Exagen, 5, 9, Quotient Therapeutics, 2, UCB, 6, Zenas, 2; M. Atta: GSK, 1, Novartis, 5; A. Rosenberg: None; S. Sanyal: None; P. Izmirly: Hansoh Bio, 2; E. Carter: None; M. Masson: None; M. Belmont: None; J. Barnas: None; J. Anolik: None; B. Rovin: Alexion, 2, Artiva, 2, 11, AstraZeneca, 2, Aurinia, 2, 5, Biogen, 2, 5, Bristol Myers Squibb, 2, Cabelleta, 2, Century, 2, F. Hoffman-La Roche Ltd/Genentech, Inc., 2, GlaxoSmithKlein(GSK), 2, Novartis, 2; J. Buyon: Artiva Biotherapeutics, 2, Biogen, 2, Bristol-Myers Squibb(BMS), 2, Celgene, 2, CLIMB Bio Operating, 2, GlaxoSmithKlein(GSK), 2, Janssen, 2, Related Sciences, 2, UCB, 2.

To cite this abstract in AMA style:

Petri M, Fava A, Atta M, Rosenberg A, Sanyal S, Izmirly P, Carter E, Masson M, Belmont M, Barnas J, Anolik J, Rovin B, Buyon J. Redefining When to Biopsy the Kidney in Patients with SLE [abstract]. Arthritis Rheumatol. 2025; 77 (suppl 9). https://acrabstracts.org/abstract/redefining-when-to-biopsy-the-kidney-in-patients-with-sle/. Accessed .

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