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Lupus nephritis: Histopathology 

Lupus nephritis: Histopathology
Lupus nephritis: Histopathology

David J. Cimbaluk

and Melvin M. Schwartz

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date: 27 September 2020

1. Is renal dysfunction caused by lupus or a non-SLE renal lesion?

Renal insufficiency in SLE may be caused by SLE-related glomerular pathology, tubulo-interstitial or vascular pathology, or non-SLE pathogenic mechanisms such as prerenal hemodynamic factors or a drug-related tubulo-interstitial nephritis. In general, if the biopsy shows active lupus nephritis (Class III or IV), renal insufficiency should be attributed to the glomerular disease. If the biopsy shows one of the less inflammatory forms or glomerular involvement (Class I, II, or V), and there is acute tubulo-interstitial nephritis, a non-lupus aetiology should be excluded, clinically. The presence of both lupus GN and tubulo-interstitial damage requires treatment of the glomerular lesion and removal of potentially damaging drugs from the therapeutic regimen.

2. How severe is the glomerular pathology?

The renal biopsy documents the presence and distribution of pathology among the glomeruli. Using these observations, the pathologist makes a diagnosis based upon the ISN/RPS classification. The prognosis (and severity) of the lesion is implicit in the class of the glomerular pathology.

3. Is the pathology reversible?

Whether the pathology seen on renal biopsy is reversible depends on the relative contribution of lesions that can be expected to heal with and without scarring. By its nature, lupus nephritis can heal with scarring, and a glomerular scar implies a loss of function. Although the extent of glomerular scarring does not correlate well with function, the associated tubular atrophy and interstitial fibrosis directly correlate with the creatinine clearance. Thus, the pathology indicates reversibility of the lesion by describing the nature and the extent of glomerular inflammation (potentially reversible in the absence of necrosis) and the extent of glomerular scarring, interstitial fibrosis and tubular atrophy (irreversible lesions).

4. How should the patient be treated?

The renal pathology makes a major contribution to the answer of this critical question. Once it has been determined that the patient has lupus nephritis, the biopsy is placed into one of the ISN/RPS classes. The glomerular pathology of Class I and II lesions receives limited treatment in the absence of systemic disease activity. The lesion-specific treatment of proliferative (Classes III and IV) and membranous (Class V) forms of lupus nephritis has been recently reviewed. When renal insufficiency results from extensive, irreversible lesions (ISN/RPS Class VI), the renal biopsy may be used to support a decision not to treat.

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