Managing lupus nephritis: algorithms for conservative use of renal biopsy

SUMMARY: Despite the widespread use of renal biopsy to guide the treatment of lupus nephritis, the disease can usually be diagnosed and managed on the basis of its clinical presentation alone. We propose a conservative approach in which biopsy is used selectively and present three algorithms that allow for a simplified initial approach to managing lupus nephritis. KEY POINTS: Although the grading systems of the World Health Organization and the National Institutes of Health for renal biopsy results are commonly used to guide the treatment of lupus nephritis, there are limits to the utility of these systems. Physicians can distinguish clinically mild lupus nephritis, the nephrotic syndrome, or the nephritic syndrome on the basis of the urine sediment, urine protein excretion, serum albumin and creatinine concentrations, and creatinine clearance, and can initiate treatment on the basis of this information, rather than performing a renal biopsy. Corticosteroids are the cornerstone of therapy for lupus nephritis, but new therapies are emerging. The nephritic syndrome reflects active disease and requires more vigorous treatment. It may be prudent to reserve renal biopsy for situations that arise later in the course of lupus nephritis, such as failure to respond to therapy based on the initial clinical presentation.