Probable lupus nephropathy: Treat it without a renal Bx?‏

Dear Nephrolnauts,

I have been recently referred a 63 y.o. male with an old history of anti-phospholipid syndrome (multiple episodes of CNS thrombosis/emboli, mnemonic and mood modifications, on anti-vitamin K treatment for years), because of recent appearance of anti-nuclear and anti-native DNA antibodies.

Further tests revealed low C3, C4 and CH50, positive anti-cardiolipin Abs, renal failure (CrCl 47 ml/mn), proteinuria (2.4 g/d), leucocyturia and hematuria. Physical showed altered vision fields and HTN.

Since this picture was compatible with SLE and lupus nephropathy, coumadinic treatment was replaced by Calciparin and a renal Bx was scheduled. Coagulation tests, however, were abnormal on the biopsy’s day and 24 H later. Given the hemorragic risks, I didn’t perform the (blind) Bx and asked a surgeon to do it coelioscopically instead. But the anesthesist contraindicated the biopsy because of the abnormal coagulation test (he maintain his position after further discussion).

Now, what would you do?

1. Look for another surgeon + anesthesist (I’m doing so).

2. Treat the patient without a renal Bx (I am inclined to do so if 1 fail).

3. Comments?

Thanks for your inputs. Best regards,

Alfredo

A. Zannier, MD, MSc

Micrograph Images:

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UPDATE

Here is an update of the above case. Around half of the public and private answers I received advocated for treatment without biopsy.

After discontinuing oral anticoagulation for a week coagulation tests were done. They showed a slight factor VII decrease, a low prothrombin time, and elongated TCA and bleeding time.

Since a second anesthesist/surgeon team refused to perform the kidney biopsy by coelioscopy I decided to proceed with the percutaneous biopsy. In the meantime (around a month) creatinine and proteinuria remained stable. I took one core. Outcome was uneventful.

There were extensive fibrosis and tubular atrophy, 25 % of obsolescent glomeruli and mild interstitial infiltrate. There was neither arterial thrombosis nor microangiopathic thrombosis. So lesions were not due to APS or SLE and were of a chronic nature.

Besides a long standing HTN (and APS) history is negative. In 1999 creatinine was 127 mcmol/l and proteinuria 250 mg/d.

Best regards,

Alfredo,

A. Zannier, MD, MSc