ACR CONVERGENCE 2020—From exploration of new biomarkers to the benefit of repeat biopsy to the promise of new therapeutics, the treatment of lupus nephritis continues to evolve, three experts said at the ACR Convergence session Lupus Nephritis: New Decade, New Approaches.
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Benefit of Repeat Biopsies
Brad Rovin, MD, Lee A. Hebert Professor of Nephrology at The Ohio State University Wexner Medical Center, discussed data pointing to benefits of performing biopsies beyond the initial diagnostic biopsy, so they can be used to help guide treatment.
In the study, 76 patients with lupus nephritis received a maintenance biopsy after the first biopsy, and immunosuppression was continued if histologic activity was present, but discontinued if it was absent.1 If those for whom the therapy was discontinued ended up flaring, induction immunosuppression was restarted.
The process of histologic evaluation and continuation or discontinuation of immunosuppression continued until no patients showed histologic activity.
After the first repeat biopsy, 21 patients showed histologic activity and continued therapy, and 55 had therapy stopped when no activity was found. Six of those patients experienced a flare.
After the second repeat biopsy, six patients continued therapy and 20 had therapy stopped, which was followed by one flare among those patients. No patients undergoing a third repeat biopsy were found to have histologic activity.
The flare rate among those managed using repeat biopsies was 0.012 per patient year, compared with the 0.059 per patient-year that has been seen among those treated with usual care, Dr. Rovin said. This translates into the need to treat 10 patients under the biopsy-managed protocol to prevent one flare. This may sound like a lot of patients, he acknowledged, but it is not out of line with that seen in many therapeutic trials. Repeat biopsy is clearly useful in helping manage patients, but he cautioned the biopsies should be performed at centers with experience in performing them.
“I think it’s a little naive to expect the initial histology will be able to predict patient outcomes or prognosis, because prognosis has to be considered in the context of other variables—access to care, adherence to medications, race, ethnicity and, most importantly, response to therapy,” Dr. Rovin said. “Even if we assume the patient is optimally treated, one snapshot of histology really can’t predict the response to therapy.”
Promise of New Therapeutics
Joan Merrill, MD, director of clinical projects in the Arthritis and Clinical Immunology Program at the Oklahoma Medical Research Foundation, Oklahoma City, discussed recent findings from trials of three drugs: the anti-CD20 obinutuzumab, the calcineurin inhibitor voclosporin and the BLyS-inhibitor belimumab.