Background/Purpose: Whether a repeat renal biopsy is helpful during lupus nephritis (LN) flares remains debatable. Our objective was to analyze the clinical utility of repeat renal biopsy in this complex situation.

Methods: From a total of 190 patients with LN treated between 1988 and 2014 at Bellvitge University Hospital (Barcelona, Spain), we selected for analysis 54 patients with two or more renal biopsies. Renal biopsy was repeated only on the basis of one of these clinical indications: 1) increase, persistence, or recurrence of proteinuria, nephrotic syndrome, or active urinary sediment (hematuria and/or cellular casts), or 2) increase in serum creatinine level or unexplained progression to renal failure. This study did not include patients with protocol biopsies performed to evaluate the response to therapy.

Additionally, we reviewed 686 well-documented similar cases previously reported (PubMed 1990-2016).

Results: The analysis of all patients reviewed showed that histological transformations are common during a LN flare, ranging from 40% to 76% of cases. However, the prevalence of transformations and the clinical value of repeat biopsy vary when they are analyzed according to proliferative or non-proliferative lesions.

The great majority of patients with class II (78% in our series and 77.5% in the literature review) progressed to a higher grade of nephritis (classes III, IV or V), resulting in worse renal prognosis. The frequency of pathological conversion in class V is lower (33% and 43%, respectively) but equally clinically relevant, since almost all cases switched to a proliferative class. Therefore, repeat biopsy is highly advisable in patients with non-proliferative LN at baseline biopsy, because these patients have a reasonable likelihood of switch to a proliferative LN that may require more aggressive immunosuppression.

In contrast, the majority of patients (82% and 73%) with proliferative classes in the reference biopsy (III, IV or mixed III/IV + V), remained into proliferative classes on repeat biopsy. Although rebiopsy in this group does not seem as necessary, it is still advisable since it will allow us to identify the 18% to 20% of patients that switch to a non-proliferative class. In addition, consistent with the reported clinical experience, repeat biopsy might also be helpful to identify selected cases with clear progression of proliferative lesions despite the initial treatment, for whom it is advisable to intensify inmunosuppression.Thus, our experience and the literature data support that repeat biopsy also brings more advantges than threats in this group.

Conclusion: Although there is still a need for new randomized, prospective studies to confirm clinical observations, in daily practice kidney repeat biopsies are useful in guiding treatment of LN flares. The results of the repeat biopsy led to a change in the immunosuppresive treatment in more than half of the patients on average, intensifying it in the majority of the cases, but also reducing it in 5% to 30%.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-value-of-repeat-biopsy-in-the-management-of-lupus-nephritis-flares/