Prognostic value of endocapillary hypercellularity in IgA nephropathy patients with no immunosuppression
Prognostic value of endocapillary hypercellularity in IgA nephropathy patients with no immunosuppression
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DOI：
10.1007/s40620-015-0227-8
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发表时间：
2016-06-01
影响因子：
3.4
通讯作者：
Roberts, Ian S. D.
中科院分区：
文献类型：
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作者：
Chakera, Aron;MacEwen, Clare;Roberts, Ian S. D.
目的伊加肾病（IgAN）回顾性临床病理研究的解释受到免疫抑制偏倚的混淆。在已发表的IgAN牛津分类验证研究中，平均33%的患者接受非随机类固醇和/或细胞毒性治疗。为了确定增殖性病变对IgAN的自然史的真实影响，对未接受免疫抑制治疗的患者队列进行分析是必需的。方法我们对未接受免疫抑制治疗的IgAN患者进行了回顾性单中心研究。根据牛津分类对活检进行评分。主要结果是肾存活率或肾功能的快速丧失，定义为eGFR下降>5 ml/min/year.Results 237例IgAN患者被确定为平均随访82个月。200例活检可供审查，其中156例足以使用牛津分类进行评分。9/156例患者（5.8%）接受了一些免疫抑制治疗，大多数用于不相关的疾病：这些被排除。在多变量考克斯回归分析中，包括组织学和临床数据，至ESRD时间的唯一独立预测因素是基线eGFR（HR 0.96/ml/min增加，p = 0.018）、基线蛋白尿（HR 1.36/加倍，p = 0.004）和毛细血管内细胞增多（HR 4.75，E1与E0相比，p < 0.001）。eGFR快速下降的独立预测因素是蛋白尿（OR 1.45/加倍，p = 0.006），毛细血管内细胞过多（与E0相比，E1的OR为3.41，p = 0.025）和肾小管萎缩/间质纤维化（T2与T0相比OR 8.77，p = 0.006）。结论在未接受免疫抑制的IgAN患者队列中，毛细血管内增生和肾小管萎缩/间质纤维化是肾功能丧失率的独立预测因子。在其他临床病理学研究中缺乏E评分的预测价值很可能是免疫抑制相关偏倚的结果。我们的研究结果为免疫抑制治疗毛细血管内型IgA肾病提供了证据。
Aim Interpretation of retrospective clinicopathological studies of IgA nephropathy (IgAN) has been confounded by immunosuppression bias. In published validation studies of the Oxford Classification of IgAN, an average of 33 % of patients received non-randomised steroid and/or cytotoxic therapy. In order to determine the true impact of proliferative lesions on the natural history of IgAN, analysis of patient cohorts that have received no immunosuppression is required.Methods We performed a retrospective single centre study of patients with IgAN managed without immunosuppressive therapy. Biopsies were scored according to the Oxford Classification. The primary outcomes were renal survival or a rapid loss of renal function defined as a decline in eGFR of >5 ml/min/year.Results 237 patients with IgAN were identified with a mean follow-up of 82 months. 200 had biopsies available for review, of which 156 were adequate for scoring using the Oxford Classification. 9/156 patients (5.8 %) received some immunosuppressive therapy, mostly for unrelated conditions: these were excluded. In multivariate COX regression, including histological and clinical data, the only independent predictors of time to ESRD were baseline eGFR (HR 0.96 per ml/min increase, p = 0.018), baseline proteinuria (HR 1.36 per doubling, p = 0.004) and endocapillary hypercellularity (HR 4.75 for E1 compared to E0, p < 0.001). Independent predictors of a rapid decline in eGFR were proteinuria (OR 1.45 per doubling, p = 0.006), endocapillary hypercellularity (OR 3.41 for E1 compared to E0, p = 0.025) and tubular atrophy/interstitial fibrosis (OR 8.77 for T2 compared to T0, p = 0.006).Conclusions In a cohort of IgAN patients receiving no immunosuppression, endocapillary proliferation and tubular atrophy/interstitial fibrosis are independent predictors of rate of loss of renal function. The lack of predictive value of E score in other clinicopathological studies is most likely a result of immunosuppression-associated bias. Our findings provide evidence to support immunosuppressive treatment of endocapillary-pattern IgAN.