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Kidney Week

Abstract: FR-OR086

Kidney Biopsy-Based Management of Maintenance Immunosuppression in Lupus Nephritis

Session Information

  • Lupus and Then Some
    November 08, 2019 | Location: Ballroom C, Walter E. Washington Convention Center
    Abstract Time: 05:30 PM - 05:42 PM

Category: Glomerular Diseases

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Malvar, Ana, Hospital Fernandez, Buenos Aires, Argentina
  • Alberton, Valeria Gabriela, Hospital Fernandez, Buenos Aires, Argentina
  • Lococo, Bruno Jorge, Hospital Fernandez, Buenos Aires, Argentina
  • Ferrari, Matias, Hospital Fernandez, Buenos Aires, Argentina
  • Delgado, Pamela, Hospital Fernandez, Buenos Aires, Argentina
  • Rovin, Brad H., Ohio State University Wexner Medical Center, Columbus, Ohio, United States
Background

The optimal duration of maintenance immunosuppression (MIS) for proliferative lupus nephritis (LN) is unknown. Management of MIS therapy must balance the risk of LN flare after IS withdrawal against the toxicities of long-term IS. We postulated that information from a protocol kidney biopsy done when withdrawal of IS is being contemplated could attenuate LN flares and improve long-term kidney outcomes, and tested this hypothesis in a large LN cohort.

Methods

A cohort of 76 Caucasian Hispanic SLE patients initiated IS for kidney-biopsy proven (Bx1) LN, was followed prospectively, re-biopsied after induction (Bx2) and again during MIS therapy (Bx3). Bx3 was done after a minimum of 36 months of IS in patients stable for at least 12 months, who had achieved a complete renal response and had no extra-renal SLE activity. Biopsies were graded using the NIH activity index (AI). If AI=0 MIS was tapered off and patients were followed for LN flare. If AI was ≥1 MIS was continued for 24 months, and patients were re-biopsied around month 68 (Bx4). If Bx4 AI=0 MIS was withdrawn; if Bx4 AI was ≥1, MIS was continued for 24 months and the decision to withdraw MIS was based on re-biopsy (Bx5).

Results

Patient outcomes are shown in the Figure. After a median follow-up of 50 months between Bx3 and last visit only 7 patients (9.2%) experienced an LN flare, no patient died, and no patient progressed to ESKD.

Conclusion

These data extend the observation that clinical remission and histologic remission even after several years of IS may be discordant. Management of MIS by histologic activity of protocol biopsies resulted in an LN flare rate of 0.012 events/patient-year, significantly better than the reported flare rates of 0.02-0.81 events/patient-year in international LN cohorts. Protocol kidney biopsies during MIS may help guide treatment duration, minimizing exposure to toxic medications and risk of LN relapse.