Should we enlarge the indication for kidney biopsy in diabetics? The con part

Abstract Diabetes is the most common cause of chronic kidney disease (CKD), a condition found in 850 million persons and projected to become the fifth global cause of death by 2040. Research is needed that examines kidney tissue to characterize distinct phenotypes in patients with DM and CKD so as to identify non-invasive biomarker signatures and develop targeted therapeutic approaches. However, from a routine care point of view, kidney biopsy is likely overused in patients with CKD and DM, as most biopsy results are not expected to be associated with a therapeutic approach that differs from standard kidney protection with triple or quadruple therapy (renin-angiotensin system blockade. SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and GLP1 receptor agonists). Moreover, expanding the kidney biopsy criteria will increase the absolute number of complications from kidney biopsies, that may reach 27 000 to 108 000 deaths of persons that would derive little benefit from kidney biopsy if all people with DM and severe CKD were biopsied globally. Finally, limited resources should be optimally allocated. The cost of one kidney biopsy may fund 7000 semiquantitative urinary albumin:creatinine ratio assessments that may identify earlier stages of the disease and allow treatment that prevents progression to a stage in which kidney biopsy may be considered.