⚡ Protocol Biopsies in Lupus Nephritis (LN)⚡
1/ Let's take another stab at (pun intended?) protocol biopsies in LN!
💡 The idea is certainly not new - it has been successfully implemented in kidney transplant recipients #NephTwitter #Tweetorial #FOAMed @NSMCInternship
1/ Let's take another stab at (pun intended?) protocol biopsies in LN!
💡 The idea is certainly not new - it has been successfully implemented in kidney transplant recipients #NephTwitter #Tweetorial #FOAMed @NSMCInternship
2/ Out of curiosity - have you asked for repeat biopsies in these patients? When & why? Does your hospital have a protocol for it? Share your experience in the comments too! 👇
3/ I mean, you nailed the diagnosis the first time around, right? So why would you ask for a repeat kidney biopsy in a patient with LN? 🤔 
4/ LN is a protean disease, able to morph from one class to another just like the Ancient Greek deity, either during treatment or spontaneously! (yay, I got to use a fancy word - protean😁) en.wikipedia.org/wiki/Proteus 🔱
5/ Its shape-shifting nature makes it troublesome because treatment changes based on histologic class! Let’s have a look at this infographic to see some possible shifts & their implications:
6/ ❗There’s a caveat ☝️ - class switches can occur WITHOUT changes in the clinical indicators! So there might not be any signs🚩to alert you when a repeat biopsy might be called for pubmed.ncbi.nlm.nih.gov/28444337/
7/ Adding up, there are no serum/urine markers (yet🤔) that can predict when LN is no longer active. So CLINICAL remission ≠ HISTOLOGIC remission, at least for proliferative LN on initial biopsy pubmed.ncbi.nlm.nih.gov/26250434/
8/ 📖 And if you’re wondering how to define clinical response/remission, let’s go over how John Feehally’s Comprehensive Clinical Nephrology describes it:
9/ 🔬 Maybe in the future we’ll see some new markers? Keep your 👀 on urinary exosomal miRNA 🧬, exostosin 1 & 2! ncbi.nlm.nih.gov/pmc/articles/P… & nature.com/articles/s4158…
10/ Some patients undergoing proteinuric remission still have histologic activity, while others in histologic remission still had significant proteinuria! Confused yet? I know I am! 😵 pubmed.ncbi.nlm.nih.gov/30045812/
11/ So if some patients with LN still have histologically active disease after years of therapy, wouldn’t it make sense to repeat biopsy in all patients and then decide whether to continue/change/withdraw treatment? 🤔
13/ Another argument for protocol biopsies would be that there’s no clear cut treatment duration because we don’t know how long it takes for disease activity to subside! 🤷
14/ And simply defaulting to extending immunosuppression indefinitely means extended risks of immunosuppression and other drug related adverse reactions...
15/ However, let’s not be one-sided! Biopsies are invasive procedures & have associated risks, mostly related to bleeding 🩸 that ranges from minor to severe⚠️(in rare cases requiring transfusions or even angiographical intervention!) pubmed.ncbi.nlm.nih.gov/22537423/
16/ ⚡ Round 2! ⚡ Considering what you’ve read so far, have you changed your opinion? When would it be optimal to repeat the biopsy?
17/ Also, here’s a handy flowchart on the topic from #NephMadness 2017 GN Region! 🔗 ajkdblog.org/2017/03/07/nep…
18/ Hopefully this controversial issue will get settled soon!
✨Meanwhile, I’d like to thank my mentors @amyaimei @DoctorGates @kidney_boy @Nephro_Sparks @saynanorouzi @Vernisartan and fellow pod members @NSMCInternship for helping me build & review this tweetorial! ✨
✨Meanwhile, I’d like to thank my mentors @amyaimei @DoctorGates @kidney_boy @Nephro_Sparks @saynanorouzi @Vernisartan and fellow pod members @NSMCInternship for helping me build & review this tweetorial! ✨
