Wednesday, December 14, 2016
Lupus Nephritis classification: Does it help us?
I recently went to a talk by Stephen Korbet on Lupus Nephritis and it got me wondering on if the current way of classification of lupus nephritis works or not?
MPGN- old way of classification was EM based but the recent updated IF based classification is very clinical and aids the clinician in treating the disease better as a root cause is identified.
In lupus, the story starts back in 1970s and eventually leading to the WHO classification and then the updated ISN classification. A recent review published in JASN in 2015 summarizes the history and concerns regarding the classifications. The suggestions to improve are more detailed and pathology related and I am not sure if they will help clinically.
What might help a nephrologist help treat the lupus nephritis patient?
1. Is the lesion Proliferative?- segmental or diffuse- most of us will treat. Only context of not treating will be the IFTA present on the biopsy- so does it matter if its segmental or diffuse? as treatment is either MMF or cyclophosphamide anyway.
2. Is the lesion crescentic? - yes this matters to us-- as most crescentic GN( RPGN) and specifically lupus have been excluded in most trials- so treatment might be leaning towards cytotoxic agents and not standard therapy.
3. Is it a podocytopathy ( would like to include membranous GN in this section)- More and more we are seeing MCD, FSGS with this entity and treatment might be slightly different as some of them respond faster with a steroid based regimen.
4. Is there a second entity with it?- ANCA disease or TMA?- as treatment might then entail pheresis and or a different prognosis.
I think the talk by Korbet hinted towards this but not sure which direction the field will go but it's time that we have a less confusing classification but more meaningful one that helps the nephrologists treat the disease better.
What do others think?
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