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Protocol Biopsy Subclinical Activity LN — ESENeph MCQ

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HardGlomerulonephritisProtocol Biopsy Subclinical Activity LNESENeph

A 35-year-old woman with lupus nephritis Class III+IV on induction therapy has a protocol renal biopsy at 12 months showing persistent activity (Activity Index 8/24) despite clinical improvement (proteinuria fell from 4 to 1 g/day). What does this discordance suggest?

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Correct answer: E — Histological response may lag behind clinical response; persistent histological activity despite clinical improvement suggests that immunosuppression should not be prematurely reduced; some experts advocate biopsy-guided therapy to detect subclinical activity

Protocol (surveillance) biopsies in lupus nephritis have revealed that clinical response (proteinuria, eGFR) does not always correlate with histological activity. Up to 30-40% of patients with apparent clinical remission have persistent histological activity ('subclinical nephritis'). This carries a higher relapse risk than patients with both clinical and histological remission. KDIGO 2024 LN guideline acknowledges that repeat biopsy may be useful in guiding treatment decisions, though it does not mandate protocol biopsies. Persistent histological activity should prevent premature immunosuppression reduction.

Reference: KDIGO 2024 – Lupus Nephritis; Alvarado et al 2014 – Protocol Biopsy LN