One of the most difficult management decisions in the care of those with LN is determining the duration of maintenance immunosuppressive therapy. Recommendations have ranged from 1 year (from the Kidney Disease Improving Global Outcomes [KDIGO] glomerulonephritis guidelines) to 3 years (from the European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association guidelines), with the ACR making no recommendations.1,16,17 

Studies suggest that repeat biopsy may be useful in making the decision to withdraw or continue maintenance immunosuppression and may offer a tool to improve the evaluation of treatment response in LN.18,19 This is particularly important among patients who show no active lesions on biopsy taken after induction therapy, and for whom continued immunosuppression exposes them to unnecessary treatment adverse events. The decision to taper or withdraw immunosuppression is not simple, however. 

Most studies of repeat biopsy after LN induction therapy show improvement in histologic activity but not resolution of inflammation.19 Therefore, a biopsy before the decision to taper immunosuppressive therapy may identify patients who still have histologic activity and in whom it may be desirable to continue or even intensify immunosuppressive therapy. In the absence of guideline recommendations, the consensus from available data suggests that repeat biopsy to inform the decision to withdraw maintenance therapy could be considered after 3 to 3.5 years of total therapy (induction + maintenance) in clinically asymptomatic patients.19

Summary and clinical applicability

Despite controversy regarding its clinical relevance and applicability, renal biopsy represents the current standard for LN classification and diagnosis and the current standard to guide treatment decisions for patients with SLE. Despite the lack of robust data, ACR guidelines for the management of LN recommend that all patients with clinical evidence of active LN, previously untreated, undergo renal biopsy (unless strongly contraindicated).

In the absence of evidence from robust randomized trials, the clinical relevance of repeat biopsy remains questionable, although small-scale studies suggest that repeat biopsy may be a useful tool to improve the evaluation of treatment response and guide the decision to withdraw or continue maintenance immunosuppression.

References

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11. Arends S, Grootscholten C, Derksen RH, et al. Long-term follow-up of a randomised controlled trial of azathioprine/methylprednisolone versus cyclophosphamide in patients with proliferative lupus nephritis. Ann Rheum Dis. 2012;71(6):966-973.

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13. Pagni F, Galimberti S, Goffredo P, et al. The value of repeat biopsy in the management of lupus nephritis: an international multicentre study in a large cohort of patients. Nephrol Dial Transplant. 2013;28(12):3014-3023.

14.Alsuwaida A, Husain S, Alghonaim M, et al. Strategy for second kidney biopsy in patients with lupus nephritis. Nephrol Dial Transplant. 2012;27(4):1472-1478.

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16. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int Suppl. 2012;2(2). http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO-GN-Guideline.pdf. Accessed March 10, 2016.

17. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771-1782.

18. Alvarado AS, Malvar A, Lococo B, et al. The value of repeat kidney biopsy in quiescent Argentinian lupus nephritis patients. Lupus. 2014;23(8):840-847.

19. Rovin BH, Parikh SV. Lupus Nephritis: The Case for Repeat Kidney Biopsy in the Management of Maintenance Therapy. http://asn.stage.bluewatermedia.com/kidney-news/special-sections/glomerular-disease/lupus-nephritis-the-case-for-repeat-kidney-biopsy-in-the-management-of-maintenance-therapy. Accessed March 10, 2016.