A Multicenter Study of the Predictive Value of Crescents in IgA Nephropathy
A Multicenter Study of the Predictive Value of Crescents in IgA Nephropathy
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DOI：
10.1681/asn.2016040433
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发表时间：
2017-02-01
影响因子：
13.6
通讯作者：
Katafuchi, Ritsuko
中科院分区：
文献类型：
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作者：
Haas, Mark;Verhave, Jacobien C.;Katafuchi, Ritsuko
伊加肾病的牛津分类不包括肾小球新月体。然而，报告新月体对肾脏结局无独立预测作用的研究排除了重度肾功能不全患者。在一个由4项回顾性研究组成的大型伊加肾病队列中，我们将新月体作为肾脏预后的预测因子，并确定含新月体肾小球的分数是否与eGFR下降≥ 50%或ESRD（联合事件）的生存率相关，并对原始牛津研究中使用的协变量进行了调整。研究的3096名受试者的初始平均eGFR为78 ± 29 ml/min/1.73 m2，中位（四分位距）蛋白尿为1.2（0.7-2.3）g/d，36%的受试者有细胞或纤维细胞新月体。总的来说，新月体预示着更高的合并事件的风险，尽管这仅在未接受免疫抑制的患者中保持显著性。在所有个体中，至少六分之一或四分之一的肾小球存在新月体与合并事件的风险比（95%置信区间）分别为1.63（1.10至2.43）或2.29（1.35至3.91）。此外，在接受和未接受免疫抑制的患者中，至少四分之一的肾小球中存在新月体与联合事件独立相关。我们建议在牛津分类中增加以下新月体评分：CO（无新月体）; C1（肾小球中新月体少于四分之一），确定患者在无免疫抑制的情况下预后不良的风险增加; C2（肾小球中新月体超过四分之一），确定患者即使在免疫抑制的情况下进展的风险更大。
The Oxford Classification of IgA nephropathy does not account for glomerular crescents. However, studies that reported no independent predictive role of crescents on renal outcomes excluded individuals with severe renal insufficiency. In a large IgA nephropathy cohort pooled from four retrospective studies, we addressed crescents as a predictor of renal outcomes and determined whether the fraction of crescent-containing glomeruli associates with survival from either a >= 50% decline in eGFR or ESRD (combined event) adjusting for covariates used in the original Oxford study. The 3096 subjects studied had an initial mean +/- SD eGFR of 78 +/- 29 ml/min per 1.73 m(2) and median (interquartile range) proteinuria of 1.2 (0.7-2.3) g/d, and 36% of subjects had cellular or fibrocellular crescents. Overall, crescents predicted a higher risk of a combined event, although this remained significant only in patients not receiving immunosuppression. Having crescents in at least one sixth or one fourth of glomeruli associated with a hazard ratio (95% confidence interval) for a combined event of 1.63 (1.10 to 2.43) or 2.29 (1.35 to 3.91), respectively, in all individuals. Furthermore, having crescents in at least one fourth of glomeruli independently associated with a combined event in patients receiving and not receiving immunosuppression. We propose adding the following crescent scores to the Oxford Classification: CO (no crescents); C1 (crescents in less than one fourth of glomeruli), identifying patients at increased risk of poor outcome without immunosuppression; and C2 (crescents in over one fourth of glomeruli), identifying patients at even greater risk of progression, even with immunosuppression.