Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative).

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

Impact of Sodium-Glucose Cotransporter-2 Inhibitors in the Management of Chronic Kidney Disease: A Middle East and Africa Perspective.

Chronic kidney disease (CKD) is a major public health concern in the Middle East and Africa (MEA) region and a leading cause of death in patients with type 2 diabetes mellitus (T2DM) and hypertension. Early initiation of sodium-glucose cotransporter - 2 inhibitors (SGLT-2i) and proper sequencing with renin-angiotensin-aldosterone system inhibitors (RAASi) in these patients may result in better clinical outcomes due to their cardioprotective properties and complementary mechanisms of action. In this review, we present guideline-based consensus recommendations by experts from the MEA region, as practical algorithms for screening, early detection, nephrology referral, and treatment pathways for CKD management in patients with hypertension and diabetes mellitus. This study will help physicians take timely and appropriate actions to provide better care to patients with CKD or those at high risk of CKD.

Renin-angiotensin-system blockers and IgG antibodies in end-stage renal disease hemodialysis-receiving patients diagnosed with COVID-19 infection.

OBJECTIVES: To evaluate the prevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections among patients receiving in-center hemodialysis (ICHD), the relationship between the IgG antibody levels against the virus and SARS-CoV-2-associated symptoms, hemodialysis adequacy, and the antihypertensives used in order to control blood pressure. METHODS: A prospective observational study was carried out at a tertiary care center, King Fahad Kidney Center, Riyadh, Kingdom of Saudi Arabia, between November 2020 and January 2021. A total of 214 ICHD patients with end-stage renal disease (ESRD) were included, and the levels of their anti-SARS-CoV-2 IgG antibodies were assessed after obtaining their informed consent. RESULTS: Our tests indicated that 15% of the patients in the study's population had detectable SARS-CoV-2 IgG antibodies, with more than half of them (53%) being asymptomatic. We also found that ESRD patients on angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) had higher levels of SARS-CoV-2 IgG antibodies than patients not receiving this group of medications. CONCLUSION: More studies are required to assess whether patients with a SARS-CoV-2 infection that do not have an indication for being prescribed ACEIs/ARBs would benefit from receiving these medications.

Chronic Kidney Disease Management in the Middle East and Africa: Concerns, Challenges, and Novel Approaches.

The burden of chronic kidney disease (CKD) and other comorbidities, such as hypertension and diabetes, which increase the risk of developing CKD, is on the rise in the Middle East and Africa. The Middle East and Africa CKD (MEA-CKD) steering committee, comprising eminent healthcare specialists from the Middle East and Africa, was formed to identify and propose steps to address the gaps in the management of CKD in these regions. The current article lists the MEA-CKD steering committee meeting outcomes and evaluates the available evidence supporting the role of novel therapeutic options for patients with CKD. The need of the hour is to address the gaps in awareness and screening, early diagnosis, along with referral and management of patients at risk. Measures to bring about appropriate changes in healthcare policies to ensure access to all benefit-proven protective therapies, including novel ones, at community levels are also vital for reducing the overall burden of CKD on the healthcare system as well as governing bodies, especially in developing countries of the Middle East and Africa.

Response to Lisinopril in Patients with Sickle Cell Anemia and Proteinuria.

Proteinuria is a manifestation of sickle cell anemia (SCA)-related renal disease and is a risk factor of renal impairment. Angiotensin-converting enzyme (ACE) inhibitors have benefits, but their role in SCA remains undefined. This study aimed to assess the role of lisinopril, an ACE inhibitor, in reducing proteinuria in SCA patients. Thirty-five patients older than 15 years with known SCA (HbSS or HbS-ß0) and a 24-h urinary protein level of 150 mg or more participated in this study. Urine was collected over 24 h to quantify proteinuria. The patients had a mean age of 28.5 ± 6.98 years. The median 24-h urinary protein before treatment was 0.3006 g and that after treatment was 0.150 g (P = 0.01). After a median follow-up of 38 months, 24-h urinary protein decreased in 27 (77%) patients and normalized in 18 (52%) patients. Urinary protein increased in 2 (6%) patients and remained stable (no change) in 6 (17%) patients. There was no significant difference in blood pressure (BP) before and after treatment. The average dose of lisinopril was 5 mg. Twenty patients were still on lisinopril at last follow-up. The reasons for stopping lisinopril included normalization of protein, noncompliance, adverse effects, and pregnancy. Lisinopril effectively reduced proteinuria in SCA patients, without significantly reducing BP. Only a few patients developed adverse effects, including coughing, dizziness, and diarrhea. It is unclear how long lisinopril should be continued and whether it can be stopped in patients with normalized urinary protein.

Improvement of clinical outcomes in dialysis: No convincing superiority in dialysis efficacy using hemodiafiltration vs high-flux hemodialysis.

Hemodiafiltration (HDF) is not associated with lower mortality risk compared to standard hemodialysis (HD). However, there are many critical clinical outcomes in dialysis patients in addition to mortality; the impact of HDF on these other outcomes is not clear. This retrospective study included all patients referred to DaVita Clinics in the Kingdom of Saudi Arabia. High-flux HD was the initial modality in all patients. Those who did not achieve adequacy targets or those with poorly controlled phosphorus were switched to postdilution HDF using 18 to 23 L exchange per treatment. Patients dialyzing with a central venous catheter, patients who dialyzed less than 90 days at DaVita, and those with interrupted HDF were excluded. Of the 1115 patients, 215 (19%) were on HDF and 900 on high-flux HD; the median follow-up was 6 months for all patients. The HDF group showed a significant reduction in serum phosphate (P < .001), a significant increase in serum calcium (P < .012) and a significant improvement in Kt/V (P < .0001). The HDF group had significantly higher hemoglobin levels than the HD group (P = .024), with a significant reduction in weekly erythropoiesis-stimulating agent dose after starting HDF (P < .001). A modified protocol that included prolonged dialysis duration, larger-sized dialyzer, faster blood flow rates, and adding hemofiltration fluid may be helpful in achieving the recommended targets. Thus, HDF can enable the achievement of adequate dialysis care in some patients. Randomized-controlled clinical trials are necessary to confirm these findings.

Influence of gender and age on haemodialysis practices: a European multicentre analysis.

BACKGROUND: Women of all ages and elderly patients of both genders comprise an increasing proportion of the haemodialysis population. Worldwide, significant differences in practice patterns and treatment results exist between genders and among younger versus older patients. Although efforts to mitigate sex-based differences have been attempted, significant disparities still exist. METHODS: This retrospective cohort study included all 1247 prevalent haemodialysis patients in DaVita units in Portugal (five dialysis centres, n = 730) and Poland (seven centres, n = 517). Demographic data, dialysis practice patterns, vascular access prevalence and the achievement of a variety of Kidney Disease: Improving Global Outcomes (KDIGO) treatment targets were evaluated in relation to gender and age groups. RESULTS: Body weight and the prescribed dialysis blood flow rate were lower in women (P < 0.001), whereas treated blood volume per kilogram per session was higher (P < 0.01), resulting in higher single-pool Kt/V in women than in men (P < 0.001). Haemoglobin was significantly higher in men (P = 0.01), but the proportion of patients within target range (10-12 g/dL) was similar. Men more often had an arteriovenous fistula than women (80% versus 73%; P < 0.01) with a similar percentage of central venous catheters. There were no gender-specific differences in terms of dialysis adequacy, anaemia parameters or mineral and bone disorder parameters, or in the attainment of KDIGO targets between women and men >80 years of age. CONCLUSIONS: This large, multicentre real-world analysis indicates that haemodialysis practices and treatment targets are similar for women and men, including the most elderly, in DaVita haemodialysis clinics in Europe.

Renal histopathology spectrum in children with kidney diseases in Saudi Arabia, 1998-2017.

OBJECTIVES: To identify the trends in the diagnostic frequency of glomerular disease subtypes by renal biopsy in children in Saudi Arabia over the last 20 years. METHODS: In this retrospective observational study, we identified all patients aged less than 18 years for whom native kidney biopsy was performed between 1998 and 2017. The period during which biopsy was performed (1998-2004, 2005-2011, and 2012-2017) and the demographic information and their association with the prevalence of various glomerular disease subtypes were our primary outcomes. Results: A total of 326 cases with renal biopsy were analyzed; the mean age of participants being 11 years and 45.4% of them were girls. Unexpectedly, secondary glomerulonephritis accounted for 42.3% of the cases, and lupus nephritis was the most common cause noted in 20.7% of the cases. The minimal change and focal segmental glomerulosclerosis were the most common glomerulonephritis in 59% of the cases. The frequency of membranoproliferative glomerulonephritis and mesangioproliferative glomerulonephritis significantly decreased from 15% and 17% in the period prior to 2004 to 3.3% (p=0.003) and 1.7% in 2012-2017 (p less than 0.001). CONCLUSIONS: We found a considerable shift in the frequency of many glomerular disease subtypes in 1998-2017, which make clinical predication of the underlying etiology challenging for clinician. Renal biopsy still remains a critical diagnostic procedure for managing a considerable proportion of renal diseases.

Prevalence and 20-year epidemiological trends of glomerular diseases in the adult Saudi population: a multicenter study.

BACKGROUND: Recent international reports have shown significant changes in the incidence of different glomerular diseases. OBJECTIVE: Examine temporal and demographic trends of biopsy-diagnosed glomerular diseases in the adult population of Saudi Arabia over the last two decades. DESIGN: Medical record review. SETTINGS: Four tertiary medical centers in Saudi Arabia. PATIENTS AND METHODS: We identified all patients that underwent native kidney biopsy between 1998 and 2017. MAIN OUTCOME MEASURES: The frequency and the disease trends in four biopsy eras (1998-2002, 2003-2007, 2008-2011, and 2012-2017) for different glomerular diseases. SAMPLE SIZE AND CHARACTERISTICS: 1070 patients, 18-65 years of age; 54.1% female. RESULTS: Of 1760 patients who underwent native kidney biopsies, 1070 met inclusion criteria. Focal segmental glomerulosclerosis was the most common biopsy-diagnosed disease, with comparable frequencies over the four eras (23.6%, 19.8%, 24.1%, and 17.1, respectively [ P value for trend=.07]). The frequency of immunoglobulin A nephropathy increased progressively. The incidence of membranoproliferative glomerulonephritis declined significantly. Among the secondary types of glomerular diseases, systemic lupus erythematosus-associated lupus nephritis was the most common, followed by diabetic nephropathy. The prevalence of diabetic nephropathy increased from 1.4% in the first era to 10.2% in the last one. CONCLUSIONS: Trends in biopsy-diagnosed glomerular disease have changed. While focal segmental glomerulosclerosis remains the most common glomerular disease, there has been a significant rise in the prevalence of immunoglobulin A nephropathy and diabetic nephropathy. In contrast, membranoproliferative glomerulonephritis has declined. LIMITATIONS: Retrospective methodologies are vulnerable to lost data. CONFLICT OF INTEREST: None.

Achievement of renal anemia KDIGO targets by two different clinical strategies - a European hemodialysis multicenter analysis.

BACKGROUND: The optimal treatment algorithm for iron therapy and the use of erythropoiesis-stimulating agents (ESA) in anemic hemodialysis (HD) patients has not been established. Hemoglobin (Hb) target levels can be achieved through more frequent intravenous (IV) iron use with lower ESA dose, or with less iron dosing but higher ESA. ESA therapy to correct anemia may result in severe arterial and venous thrombotic complications and the evidence base evaluating hard clinical outcomes related to the use of IV iron is sparse. METHODS: A total of 1247 maintenance HD patients from 12 dialysis centers in Portugal (n = 730) and Poland (n = 517) were considered. We assessed achievement of KDIGO renal anemia targets with focus on treatment strategies, which typically differ between countries. In Poland the use and dose of IV iron was 35-72% higher than that in Portugal (p <  0.001) during three consecutive months; use and dose of ESA was 61% higher in Portugal (5034 vs 3133 IU (adjusted)/week, p <  0.001). RESULTS: Mean Hb concentration was similar (11.0 vs 11.0 g/dL) in patients treated in both countries and the proportion of patients within KDIGO anemia target was 69.5% in Poland vs 65.8% in Portugal (NS). Ferritin and TSAT levels and the proportion of patients with TSAT > 20 and > 50% were both significantly higher in patients in Poland (88.8 and 14.6%) than in Portugal (76.3 and 5.7% respectively, p <  0.001). Significantly more patients in Poland had a ferritin concentration > 800 µg/L (35.6%) compared to Portugal (15.8%, p <  0.001). The ESA resistance index (ERI) was significantly higher in patients treated in Portugal (p <  0.001). Correlation analyses showed confounding by treatment indication in unadjusted models. Multiple and logistic regression analyses showed that with ferritin within KDIGO recommended range of 200-800 µg/L the odds for Hb within guidelines increased significantly. Annual gross mortality was 16% in Poland and 13% in Portugal (NS); there were no differences in cause-specific mortality. CONCLUSIONS: Administration of high doses of IV iron in routine clinical HD practice may not be associated with considerable harm. However, large randomized controlled trials are needed to provide absolute evidence of iron safety.

The long-term outcomes and histological transformation in class II lupus nephritis.

OBJECTIVES: To examined the short and long-term outcome of class II lupus nephritis (LN).   Methods: This retrospective study included patients with class II LN at their first renal biopsy between January 1996 and December 2016 in King Khaled University Hospital, Riyadh, Saudi Arabia. The rate of complete remission, worsening renal function, and histological transformation in the second biopsy were examined.   Results: The study included 32 female patients with class II LN. The most frequent presentation (62.5% of patients) was hematuria with subnephrotic range proteinuria. The clinical presentation included acute kidney injury in 22% of patients, and 9.4% had nephrotic range proteinuria. Management with steroid monotherapy in 25 patients resulted in complete remission for 92% of these patients at 6 months. After a median follow up of 8 years, 2 patients had a doubling of their serum creatinine. During the follow up 17 patients (53%) needed a second biopsy, which revealed  transformation to other classes (65%).  Conclusions: Daily steroid monotherapy may be an appropriate first-line treatment for class II LN that presents with subnephrotic range proteinuria and normal kidney function. Patients with acute kidney injury and/or nephrotic range proteinuria may warrant more aggressive immunosuppressive regimens.

Focal and segmental glomerulosclerosis in murine models: a histological and ultrastructural characterization with immunohistochemistry correlation of glomerular CD44 and WT1 expression.

AIM: Focal segmental glomerulosclerosis (FSGS) is a common progressive chronic renal disease. Podocyte injury and loss are the postulated pivotal events that trigger FSGS. In this study, the authors aim to examine the evolution of FSGS in murine models histologically, ultrastructurally and immunohistochemically with special emphasis on podocytes and parietal epithelial cells (PECs). MATERIAL AND METHODS: FSGS resembling primary FSGS in humans was initiated in Wistar rats using intravenous Adriamycin injections. Blood and urine analysis were performed at 0, 8, and 12 weeks. Both the control kidneys and the test kidneys were harvested at 8 and 12 weeks, examined histologically and ultrastructurally and the findings correlated with the glomerular expression of immunostains specific for podocytes (WT-1) and for activated PECs (CD44). RESULTS: FSGS developed in both 8 and 12 weeks test groups showing progressive proteinuria, podocytopathy and segmental glomerular scarring. There was a decrease in the glomerular expression of WT-1 with a concurrent increase in the glomerular expression of CD44, indicating podocyte loss with synchronous increase in activated PECs. The evolving FSGS correlated negatively with podocytes and positively with activated PECs. CONCLUSION: Our study shows that with podocyte injury there is podocyte effacement and loss, proteinuria, glomerular segmental adhesion and scarring, all culminating in FSGS. In addition, there is activation, hyperplasia and hypertrophy of PECs. This demonstrates that both podocyte loss and PEC activation promote FSGS. Our findings are consistent with recent investigations. More studies are required to further understand the role of these cells in the evolution of FSGS and subsequently introduce new targeted treatment modalities.

Let Us Listen to Patients: Underutilization of Peritoneal Dialysis from Patients' Perspectives.

Despite the fact that many of the medical outcome data of peritoneal dialysis (PD) have been improving over the past few years, PD remains an underutilized modality in many countries worldwide. Most nephrologists in those countries report a high rate of patients' refusal. We conducted this survey-based study to determine the obstacles behind underutilization of PD in Saudi Arabia from patients' perspectives and to understand the reasons for their refusal. Nine-hundred and twenty hemodialysis (HD) patients, who had never been on PD before, participated in this study. Responses obtained from patients indicate that their refusal of PD could be because they had not received proper counseling and education about PD from their treating nephrologists throughout the course of their disease.

Effects of Ramadan fasting on moderate to severe chronic kidney disease. A prospective observational study.

OBJECTIVES: To examin the effect of Ramadan fasting on worsening of renal function (WRF). Method: This was a single-arm prospective observational study including 65 patients with stage 3 or higher chronic kidney disease (CKD). By definition, WRF was considered to have occurred when serum creatinine levels increased by 0.3 mg/dL (26.5 µmol/l) from baseline during or within 3 months after Ramadan. The study was conducted in the Nephrology Clinic of King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia during the month of Ramadan 1436 AH (Hijiri), which corresponded to June 18-July 17, 2015.  Results: This study included 65 adults with a mean age of 53 years. Overall, 33% of patients developed WRF. In the multivariate analysis, more advanced CKD stage, higher baseline systolic blood pressure and younger age were independently associated with WRF. Underlying cause of CKD, use of diuretics, use of renin angiotensin blockers, gender, and smoking status were not associated with WRF.  Conclusion: In patients with stage 3 or higher CKD, Ramadan fasting during the summer months was associated with worsening of renal function. Clinicians need to warn CKD patients against Ramadan fasting.

Prognostic significance of C1q deposition in serial biopsies for predicating the long-term outcome in patients with proliferative lupus nephritis.

Lupus nephritis (LN) is characterized by a highly variable clinical course. It has been reported that histopathologic lesions are risk factors for the progression of LN. The aim of this study is to investigate the relationship among the co-deposition of C1q, clinicopathological features, and renal outcomes in patients with LN. The clinical and histological parameters were studied in patients with International Society of Nephrology/Renal Pathology Society Class III or IV LN, who underwent two kidney biopsies. The patients were divided into two groups based on the glomerular C1q deposits: C1q-positive and C1q-negative. The impact of C1q status and longterm renal outcome on the doubling of serum creatinine and the rate of remission in the two groups were further investigated. Fifty-three patients had pure proliferative nephritis and 37.7% of these had a co-deposition of C1q. Doubling of serum creatinine was observed in 25% of patients with C1q-positive and 24.2% of patients with C1q-negative deposits. There was no difference between the two groups in terms of achieving complete or partial remission. The renal survival in the two groups was similar (P = 0.75). Upon repeat biopsy, the persistence of C1q positivity was associated with a poor outcome (P = 0.007). C1q deposition in the glomerulus in the baseline biopsy was not associated with a poor renal outcome or severe pathologic features in patients with proliferative LN. However, the persistence of C1q positivity in repeat kidney biopsy is associated with a poor renal outcome.

Carbonic anhydrase II deficiency: report of a novel mutation.

Carbonic anhydrase II (CAII) deficiency is an autosomal recessive disorder characterized by renal tubular acidosis, osteopetrosis, recurrent bone fractures, renal stones, growth failure, and mental retardation. Several cases have been reported in Saudi Arabia with homozygous mutations in CA2 consistent with a high degree of consanguinity. We report a case of carbonic anhydrase II deficiency with short stature, mixed renal tubular acidosis, recurrent bone fractures due to trivial trauma, recurrent renal stones and cerebral calcification. This patient was compound heterozygous for a novel CA2 mutation and a previously reported mutation in Arabs.

Glomerular necrotic lesions and long-term outcomes among patients with proliferative lupus nephritis.

OBJECTIVES: Although necrotic lesions are common in proliferative lupus nephritis (LN), little is known about the impact of these lesions on outcomes. This study was undertaken to investigate the impact of glomerular necrotic lesions on renal outcomes of doubling serum creatinine in patients with class III and IV LN and necrotic lesions. METHODS: 52 patients with ISN/RPS class III or IV LN were enrolled in this retrospective study, with mean follow-up of 7.4 years. All patients underwent a repeat biopsy at 12-18 months after a baseline biopsy. RESULTS: The prevalence of necrotizing lesions was observed in 24% of those with class III versus 70.4% with class IV (P=0.001). The rate of no remission was 44% and 22.2% in those with and without necrosis (P=0.007), respectively. The doubling of serum creatinine was observed in 32% of those with necrosis and in 14.8% with no necrosis (P=0.01). The chronicity index in the repeat biopsy was significantly worse among those with necrosis. CONCLUSIONS: Glomerular necrosis identifies lupus nephritis patients at the greatest risk for progression to renal failure. Proactive intervention and possibly more aggressive induction therapies in patients with necrotizing lesions may protect the kidneys from developing chronic renal impairment.

Rituximab as a rescue therapy in patients with glomerulonephritis.

To evaluate the use of rituximab in the treatment of severe glomerulonephritis (GN) in order to prevent progression of kidney disease toward the end stage, we designed a multicenter, retrospective study in Saudi Arabia about the efficacy and safety of the use of "off label" rituximab in a variety of severe refractory GN to conventional treatment and the progression of kidney disease for at least one year of follow-up. All the patients had kidney biopsies before treatment with rituximab, and proteinuria and glomerular filtration rate (GFR) were followed-up for the period of the study. The immediate side-effect at the time of administration of rituximab included itching in three patients, hypotension in one patient and anaphylaxis in one patient (dropped out from the study). After the administration of rituximab in 42 patients and during the first six months of therapy, 16 (38%) patients had complete remission (CR), 13 (31%) patients had partial remission (PR) and 13 (31%) patients had no remission. The mean follow-up period for the patients was 19.0 ± 6.97 months (median 18.0 months). The long-term follow-up during the study period disclosed a good hospitalization record for almost all of the patients. Membranous GN (MGN) was the largest group in the cohort (58% of the patients), and we observed CR and PR in 40% and 28% of them, respectively, which was comparable with the previous experience with rituximab in MGN patients with more CR than PR in our cohort. We conclude that our study suggests the safety and efficacy of the use of rituximab in patients with refractory GN and that larger and long-term prospective studies are required to define the role of rituximab in the different categories of these diseases.

Prevalence of vitamin D deficiency in peritoneal dialysis patients.

Peritoneal dialysis (PD) patients have a high risk of developing vitamin D deficiency as 25(OH) vitamin D, the precursor of active vitamin D, is lost during dialysis. This cross-sectional study was conducted to investigate the prevalence of vitamin D deficiency among adult Saudi patients on regular PD The data was collected in the summer of 2010 from patients who were on PD for more than six months at the King Khalid University Hospital, Riyadh. We recorded the demographic and clinical parameters for all patients. Blood samples were taken for serum vitamin D level (25 OH), serum parathyroid hormone (PTH) levels and other necessary biochemical parameters. There were 27 patients (11 males and 16 females) with a mean age of 46 (15-78 ± 21) years. Five patients were on continuous ambulatory PD and 22 patients were using automated PD. The average time on PD was 27.5 (6-84 ± 18.5) months. The mean serum vitamin D 25 (OH) level was 16.1 (4.9-41.5 ± 8.23) nmol/L. Sixteen (59.2%) of the patients had levels below 15 nmol/L, while another eight patients (29.6%) had vitamin D levels between 15 and 25 nmol/L, indicating a marked deficiency. The mean serum calcium was 2.2 (1.7-2.6 ± 0.2) mmol/L and the mean serum phosphorous was 1.48 (0.64-2.22 ± 0.37) mmol/L. Fifteen patients (55.5%) had significant hyperparathyroidism (serum PTH levels above 30 pmol/L). Majority of the PD patients in our center had vitamin D deficiency. The possible reasons include chronic renal failure, dietary restrictions, loss of vitamin D and decreased exposure to sunlight.

The clinical significance of serial kidney biopsies in lupus nephritis.

OBJECTIVES: Repeated kidney biopsies are increasingly recognized to be pivotal in the management of various phases of lupus nephritis. The aim of this retrospective study was to examine the shift in activity index and chronicity index among International Society of Nephrology/Renal Pathology Society (ISN/RPS) class patients with lupus nephritis who undergo a triple kidney biopsy. METHODS: Eleven patients with lupus nephritis and 3 biopsies each were assessed and reclassified based on ISN/RPS classification. RESULTS: The mean creatinine level increased from 74 (± 38) µmol/l at baseline to 129 (± 116) µmol/l at the second biopsy and to 204 (± 200) µmol/l at the last biopsy. Among 11 kidney biopsies, 7 (63.7%) had a different ISN/RPS class in the second biopsy. The third biopsy showed that six kidney biopsies had a different ISN/RPS class compared to the second biopsy. Even among patients who stayed in the same ISN/RPS class, the second and third biopsies gave a different activity and/or chronicity index. The median activity index (range) was 3.1 (0-14), 4 (0-13) and 3 (0-14) for the first, second and third biopsies, respectively. The median chronicity indices (range) were 2.5 (0-8), 7 (0-8) and 5 (0-10), respectively. CONCLUSION: My study has shown that lupus nephritis is a shifting disease, and repeated biopsies are a pivotal policy in its management.