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Testa F, Fontana F, Pollastri F, Chester J, Leonelli M, Giaroni F, Gualtieri F, Bolelli F, Mancini E, Nordio M, Sacco P, Ligabue G, Giovanella S, Ferri M, Alfano G, Gesualdo L, Cimino S, Donati G, Grana C, Magistroni R. Automated Prediction of Kidney Failure in IgA Nephropathy with Deep Learning from Biopsy Images. Clin J Am Soc Nephrol 2022; 17:1316-1324. [PMID: 35882505 PMCID: PMC9625090 DOI: 10.2215/cjn.01760222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/27/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Digital pathology and artificial intelligence offer new opportunities for automatic histologic scoring. We applied a deep learning approach to IgA nephropathy biopsy images to develop an automatic histologic prognostic score, assessed against ground truth (kidney failure) among patients with IgA nephropathy who were treated over 39 years. We assessed noninferiority in comparison with the histologic component of currently validated predictive tools. We correlated additional histologic features with our deep learning predictive score to identify potential additional predictive features. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Training for deep learning was performed with randomly selected, digitalized, cortical Periodic acid-Schiff-stained sections images (363 kidney biopsy specimens) to develop our deep learning predictive score. We estimated noninferiority using the area under the receiver operating characteristic curve (AUC) in a randomly selected group (95 biopsy specimens) against the gold standard Oxford classification (MEST-C) scores used by the International IgA Nephropathy Prediction Tool and the clinical decision supporting system for estimating the risk of kidney failure in IgA nephropathy. We assessed additional potential predictive histologic features against a subset (20 kidney biopsy specimens) with the strongest and weakest deep learning predictive scores. RESULTS We enrolled 442 patients; the 10-year kidney survival was 78%, and the study median follow-up was 6.7 years. Manual MEST-C showed no prognostic relationship for the endocapillary parameter only. The deep learning predictive score was not inferior to MEST-C applied using the International IgA Nephropathy Prediction Tool and the clinical decision supporting system (AUC of 0.84 versus 0.77 and 0.74, respectively) and confirmed a good correlation with the tubolointerstitial score (r=0.41, P<0.01). We observed no correlations between the deep learning prognostic score and the mesangial, endocapillary, segmental sclerosis, and crescent parameters. Additional potential predictive histopathologic features incorporated by the deep learning predictive score included (1) inflammation within areas of interstitial fibrosis and tubular atrophy and (2) hyaline casts. CONCLUSIONS The deep learning approach was noninferior to manual histopathologic reporting and considered prognostic features not currently included in MEST-C assessment. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_07_26_CJN01760222.mp3.
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Affiliation(s)
- Francesca Testa
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
| | - Francesco Fontana
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
| | - Federico Pollastri
- Department of Engineering "Enzo Ferrari," University of Modena and Reggio Emilia, Modena, Italy
| | - Johanna Chester
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Leonelli
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
| | - Francesco Giaroni
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
| | - Fabio Gualtieri
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Bolelli
- Department of Engineering "Enzo Ferrari," University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Mancini
- U.O. Nefrologia, Dialisi, Ipertensione, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maurizio Nordio
- Nephrology and Dialysis Unit, Unità Locale Socio Sanitaria 15 (ULSS 15), Camposampiero-Cittadella, Padua, Italy
| | - Paolo Sacco
- Nephrology and Dialysis Unit, Azienda Sanitaria Locale 3 (ASL 3), Genoa, Italy
| | - Giulia Ligabue
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Giovanella
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Ferri
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gaetano Alfano
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro," Bari, Italy
| | - Simonetta Cimino
- Nephrology and Dialysis, Azienda Unità Sanitaria Locale (AUSL) Modena, Modena, Italy
| | - Gabriele Donati
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Costantino Grana
- Department of Engineering "Enzo Ferrari," University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Magistroni
- Division of Nephrology, Dialysis and Renal Transplantation, Azienda Ospedaliera Universitaria Policlinico di Modena, Modena, Italy
- Department of Surgery, Medicine, Dental Medicine and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Impact of Consensus Definitions on Identification of Glomerular Lesions by Light and Electron Microscopy. Kidney Int Rep 2022; 7:78-86. [PMID: 35005316 PMCID: PMC8720667 DOI: 10.1016/j.ekir.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction In 2020, a working group of 13 renal pathologists published consensus definitions for 47 individual glomerular lesions found on light microscopy (LM) and 47 glomerular lesions and 9 normal structures found on electron microscopy (EM). Methods To test the impact of these definitions on identification of these lesions and structures, 2 surveys were circulated to all members of the Renal Pathology Society (RPS), each having 32 images (19 LM, 13 EM) and accompanying questions with 5 multiple-choice answers, one being the consensus choice of the working group. The first survey (survey 1 [S1]), answered by 297 RPS members, was sent in September 2020, before publication of the consensus definitions. The second (survey 2 [S2]), with images of the same lesions and structures (but not the same images) and the same questions and multiple choices in different order, was sent in April 2020, 5 months after the publication of the definitions. Results S2 was taken by 181 RPS members; 64% also took S1 and 61% reported having read the definitions paper (def. paper). Mean agreement with the consensus answers increased modestly between the 2 surveys (65.2% vs. 72.0%, P = 0.097); the increase was greater and significant when only respondents to S2 who read the def. paper were considered (65.2% vs. 74.8%, P = 0.026). Furthermore, in S2 agreement with consensus answers was greater among respondents who read this paper versus those who did not (66.9% vs. 74.8%, P < 0.0001). Conclusions Publication of the consensus definitions modestly improved interobserver agreement in identification of glomerular lesions.
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El Hag IA, Johnston J, Alessa E, Al Shammari M. Revised Bethesda System for Reporting Thyroid Cytology: Lessons learned from an appraisal of 5 years of experience in a central hospital. Cytopathology 2021; 32:482-492. [PMID: 33772905 DOI: 10.1111/cyt.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Bethesda System for Reporting Thyroid Cytology (BSFRTC) is widely adopted in the management of thyroid nodules. The system was updated in 2017, and its impact is the subject of this paper. METHODS All thyroid fine needle aspirations from 2016-2020 using the BSFRTC, with follow-up surgical pathology, were reviewed. The risk of neoplasia (RON), risk of malignancy (ROM), RON/ROM ratio, and surgical follow-up rate were determined for each diagnostic category with cytohistological correlation. ROM was calculated in two separate manners, with non-invasive follicular tumours with papillary-like nuclear features (NIFTP) counted as malignant or non-malignant. Sensitivity, specificity, negative and positive predictive values were determined for indeterminate categories: atypia of undetermined significance (AUS), suspicious for follicular neoplasm (SFN), and suspicious for malignancy (SFM). RESULTS RON, ROM, and the surgical follow-up rate increased steadily from the benign through intermediate to malignant categories. The omission of NIFTP from malignant lesions reduced the calculated ROM in indeterminate categories and improved the stratification between AUS and SFN. ROM in AUS was distinct from SFN. AUS has a well-balanced sensitivity and specificity favouring a screening rather than a diagnostic category. The calculated RON/ROM was significantly higher in AUS (1.56), compared to SFN (1.03) and SM (1.05), in agreement with current BSRTC management recommendations. CONCLUSIONS AUS is an important screening category and should remain with the addition of subcategorisation. RON and surgical follow-up rates are essential quality indicators. The RON/ROM ratio could be utilised to determine appropriate management for each diagnostic category on an institutional basis.
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Affiliation(s)
- Imad A El Hag
- Department of Pathology, Security Force Hospital, Riyadh, Saudi Arabia
| | - Jon Johnston
- Department of Pathology, Security Force Hospital, Riyadh, Saudi Arabia
| | - Ebtehal Alessa
- Department of Pathology, Security Force Hospital, Riyadh, Saudi Arabia
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Cicalese PA, Mobiny A, Shahmoradi Z, Yi X, Mohan C, Van Nguyen H. Kidney Level Lupus Nephritis Classification Using Uncertainty Guided Bayesian Convolutional Neural Networks. IEEE J Biomed Health Inform 2021; 25:315-324. [PMID: 33206612 DOI: 10.1109/jbhi.2020.3039162] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The kidney biopsy based diagnosis of Lupus Nephritis (LN) is characterized by low inter-observer agreement, with misdiagnosis being associated with increased patient morbidity and mortality. Although various Computer Aided Diagnosis (CAD) systems have been developed for other nephrohistopathological applications, little has been done to accurately classify kidneys based on their kidney level Lupus Glomerulonephritis (LGN) scores. The successful implementation of CAD systems has also been hindered by the diagnosing physician's perceived classifier strengths and weaknesses, which has been shown to have a negative effect on patient outcomes. We propose an Uncertainty-Guided Bayesian Classification (UGBC) scheme that is designed to accurately classify control, class I/II, and class III/IV LGN (3 class) at both the glomerular-level classification task (26,634 segmented glomerulus images) and the kidney-level classification task (87 MRL/lpr mouse kidney sections). Data annotation was performed using a high throughput, bulk labeling scheme that is designed to take advantage of Deep Neural Network's (or DNNs) resistance to label noise. Our augmented UGBC scheme achieved a 94.5% weighted glomerular-level accuracy while achieving a weighted kidney-level accuracy of 96.6%, improving upon the standard Convolutional Neural Network (CNN) architecture by 11.8% and 3.5% respectively.
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The ISN/RPS 2016 classification predicts renal prognosis in patients with first-onset class III/IV lupus nephritis. Sci Rep 2021; 11:1525. [PMID: 33452282 PMCID: PMC7810677 DOI: 10.1038/s41598-020-78972-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/23/2020] [Indexed: 01/27/2023] Open
Abstract
Lupus nephritis (LN) is a life-threatening complication of systemic lupus erythematosus. The 2003 pathological classification of LN was revised in 2016; it quantitatively evaluates the interstitium in addition to the glomeruli. We performed a retrospective multi-centre cohort study and investigated the utility of the 2016 classification—including the activity index (AI), chronicity index (CI), and each pathological component to predict complete remission or renal function decline, defined as 1.5-fold increase in serum creatinine levels—and compare with that of the 2003 classification. Ninety-one consecutive adult patients with first-onset class III/IV LN who were newly prescribed any immunosuppressants were enrolled and followed up for a median of 51 months from January 2004. Cox regression analysis demonstrated the subclasses based on the 2003 classification, which mainly evaluate glomerular lesions, were not associated with clinical outcomes. After adjustments for estimated glomerular filtration rate and urinary protein levels, higher CI and higher interstitial fibrosis and lower hyaline deposit scores were associated with renal functional decline. Similarly, higher CI and interstitial inflammation scores were associated with failure to achieve complete remission. Therefore, the 2016 classification can predict the clinical outcomes more precisely than the 2003 classification.
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Honeyman C, Stark H, Wang HC, Hester J, Issa F, Giele H. Biomarker and surrogate development in vascularised composite allograft transplantation: Current progress and future challenges. J Plast Reconstr Aesthet Surg 2020; 74:711-717. [PMID: 33436335 DOI: 10.1016/j.bjps.2020.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/22/2020] [Indexed: 12/23/2022]
Abstract
Vascularised composite allograft (VCA) transplantation is now a feasible reconstructive option for patients who have suffered significant soft tissue injuries. However, despite numerous technical advances in the field over two decades, a number of challenges remain, not least the management of transplant rejection. Part of the difficulty faced by clinicians is the early recognition and prevention of acute rejection episodes. Whilst this is potentially easier in VCAs than solid organ transplants, due to their visible skin component, at present the only validated method for the diagnosis of acute rejection is histological examination of a tissue biopsy. The aim of this review article is to provide an evidence-based overview of progress in the field of VCA biomarker discovery, including immune cell subsets, immune cell effector pathways, and circulating markers of allograft damage, and to discuss future challenges in the field.
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Affiliation(s)
- Calum Honeyman
- Canniesburn Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Helen Stark
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, Oxford, United Kingdom
| | - Hayson Chenyu Wang
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Joanna Hester
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Fadi Issa
- Transplant Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Department of Plastic, Reconstructive and Burns Surgery, Stoke Mandeville Hospital, Aylesbury, United Kingdom
| | - Henk Giele
- Department of Plastic, Reconstructive and Hand Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, Oxford, United Kingdom.
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Hou J, Nast CC. Artificial Intelligence: The Next Frontier in Kidney Biopsy Evaluation. Clin J Am Soc Nephrol 2020; 15:1389-1391. [PMID: 32938618 PMCID: PMC7536757 DOI: 10.2215/cjn.13450820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Jean Hou
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
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Haas M, Seshan SV, Barisoni L, Amann K, Bajema IM, Becker JU, Joh K, Ljubanovic D, Roberts ISD, Roelofs JJ, Sethi S, Zeng C, Jennette JC. Consensus definitions for glomerular lesions by light and electron microscopy: recommendations from a working group of the Renal Pathology Society. Kidney Int 2020; 98:1120-1134. [PMID: 32866505 DOI: 10.1016/j.kint.2020.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/15/2020] [Accepted: 08/19/2020] [Indexed: 01/10/2023]
Abstract
Over the past 2 decades, scoring systems for multiple glomerular diseases have emerged, as have consortia of pathologists and nephrologists for the study of glomerular diseases, including correlation of pathologic findings with clinical features and outcomes. However, one important limitation faced by members of these consortia and other renal pathologists and nephrologists in both investigative work and routine practice remains a lack of uniformity and precision in clearly defining the morphologic lesions on which the scoring systems are based. In response to this issue, the Renal Pathology Society organized a working group to identify the most frequently identified glomerular lesions observed by light microscopy and electron microscopy, review the literature to capture the published definitions most often used for each, and determine consensus terms and definitions for each lesion in a series of online and in-person meetings. The defined lesions or abnormal findings are not specific for any individual disease or subset of diseases, but rather can be applied across the full spectrum of glomerular diseases and within the context of the different scoring systems used for evaluating and reporting these diseases. In addition to facilitating glomerular disease research, standardized terms and definitions should help harmonize reporting of medical kidney diseases worldwide and lead to more-precise diagnoses and improved patient care.
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Affiliation(s)
- Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Surya V Seshan
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Laura Barisoni
- Department of Pathology, Duke University, Durham, North Carolina, USA
| | - Kerstin Amann
- Department of Nephropathology, Friedrich-Alexander University, Erlangen-Nürnberg, Germany
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Ulrich Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Danica Ljubanovic
- Department of Pathology, Dubrava University Hospital, Zagreb Medical School, Zagreb, Croatia
| | - Ian S D Roberts
- Department of Cellular Pathology, Oxford University Hospitals, Oxford, UK
| | - Joris J Roelofs
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Artificial intelligence and machine learning in nephropathology. Kidney Int 2020; 98:65-75. [PMID: 32475607 DOI: 10.1016/j.kint.2020.02.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/03/2020] [Accepted: 02/12/2020] [Indexed: 12/15/2022]
Abstract
Artificial intelligence (AI) for the purpose of this review is an umbrella term for technologies emulating a nephropathologist's ability to extract information on diagnosis, prognosis, and therapy responsiveness from native or transplant kidney biopsies. Although AI can be used to analyze a wide variety of biopsy-related data, this review focuses on whole slide images traditionally used in nephropathology. AI applications in nephropathology have recently become available through several advancing technologies, including (i) widespread introduction of glass slide scanners, (ii) data servers in pathology departments worldwide, and (iii) through greatly improved computer hardware to enable AI training. In this review, we explain how AI can enhance the reproducibility of nephropathology results for certain parameters in the context of precision medicine using advanced architectures, such as convolutional neural networks, that are currently the state of the art in machine learning software for this task. Because AI applications in nephropathology are still in their infancy, we show the power and potential of AI applications mostly in the example of oncopathology. Moreover, we discuss the technological obstacles as well as the current stakeholder and regulatory concerns about developing AI applications in nephropathology from the perspective of nephropathologists and the wider nephrology community. We expect the gradual introduction of these technologies into routine diagnostics and research for selective tasks, suggesting that this technology will enhance the performance of nephropathologists rather than making them redundant.
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Dasari S, Chakraborty A, Truong L, Mohan C. A Systematic Review of Interpathologist Agreement in Histologic Classification of Lupus Nephritis. Kidney Int Rep 2019; 4:1420-1425. [PMID: 31701051 PMCID: PMC6829183 DOI: 10.1016/j.ekir.2019.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Lupus nephritis (LN) is one of the most severe manifestations of systemic lupus erythematosus (SLE), resulting in increased morbidity and mortality. The gold standard for diagnosis of LN is a renal biopsy. Considering the importance of the biopsy in determining long-term prognostication and treatment decisions, it is crucial to assess renal histopathology with utmost accuracy and precision. This review represents a systematic search of published literature to estimate the degree of interpathologist reproducibility in current assessment of LN. Methods Using the PubMed and Google Scholar search engines, studies analyzing the agreement of 4 or more pathologists assessing LN slides using the ISN/Renal Pathology Society (RPS) classification, activity index, and chronicity index were selected for analysis in this systematic review. Results In reviewing 6 qualifying studies (those analyzing the agreement of 4 or more pathologists using the ISN/RPS classification, activity index, and chronicity index) for the assignment of ISN/RPS class was 0.325 (interquartile range [IQR] 0.2405–0.425), which is “poor.” The median interpathologist concordance values for the assigned activity index and chronicity index were “moderate”: 0.52 (IQR 0.51–0.69) and 0.49 (IQR 0.36–0.58), respectively. Conclusion Thus, the current scoring using the ISN/RPS classification system and activity and chronicity indices for LN exhibits poor interpathologist agreement, which limits its use in clinical practice. Given that this can have severe repercussions on a patient’s treatment and prognosis, efforts to update pathology assessment guidelines, objectively measurable biomarkers, and deep learning approaches are strongly warranted.
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Affiliation(s)
- Shobha Dasari
- Department of Biomedical Engineering, University of Houston, Houston, Texas, USA
| | - Ashish Chakraborty
- Department of Biomedical Engineering, University of Houston, Houston, Texas, USA
| | - Luan Truong
- Houston Methodist Research Institute, Houston, Texas, USA
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, Texas, USA
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Smith EMD, Eleuteri A, Goilav B, Lewandowski L, Phuti A, Rubinstein T, Wahezi D, Jones CA, Marks SD, Corkhill R, Pilkington C, Tullus K, Putterman C, Scott C, Fisher AC, Beresford MW. A Markov Multi-State model of lupus nephritis urine biomarker panel dynamics in children: Predicting changes in disease activity. Clin Immunol 2018; 198:71-78. [PMID: 30391651 DOI: 10.1016/j.clim.2018.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND A urine 'biomarker panel' comprising alpha-1-acid-glycoprotein, ceruloplasmin, transferrin and lipocalin-like-prostaglandin-D synthase performs to an 'excellent' level for lupus nephritis identification in children cross-sectionally. The aim of this study was to assess if this biomarker panel predicts lupus nephritis flare/remission longitudinally. METHODS The novel urinary biomarker panel was quantified by enzyme linked immunoabsorbant assay in participants of the United Kingdom Juvenile Systemic Lupus Erythematosus (UK JSLE) Cohort Study, the Einstein Lupus Cohort, and the South African Paediatric Lupus Cohort. Monocyte chemoattractant protein-1 and vascular cell adhesion molecule-1 were also quantified in view of evidence from other longitudinal studies. Serial urine samples were collected during routine care with detailed clinical and demographic data. A Markov Multi-State model of state transitions was fitted, with predictive clinical/biomarker factors assessed by a corrected Akaike Information Criterion (AICc) score (the better the model, the lower the AICc score). RESULTS The study included 184 longitudinal observations from 80 patients. The homogeneous multi-state Markov model of lupus nephritis activity AICc score was 147.85. Alpha-1-acid-glycoprotein and ceruloplasmin were identified to be the best predictive factors, reducing the AICc score to 139.81 and 141.40 respectively. Ceruloplasmin was associated with the active-to-inactive transition (hazard ratio 0.60 (95% confidence interval [0.39, 0.93])), and alpha-1-acid-glycoprotein with the inactive-to-active transition (hazard ratio 1.49 (95% confidence interval [1.10, 2.02])). Inputting individual alpha-1-acid-glycoprotein/ceruloplasmin values provides 3, 6 and 12 months probabilities of state transition. CONCLUSIONS Alpha-1-acid-glycoprotein was predictive of active lupus nephritis flare, whereas ceruloplasmin was predictive of remission. The Markov state-space model warrants testing in a prospective clinical trial of lupus nephritis biomarker led monitoring.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Eleuteri
- Medical Physics and Clinical Engineering, and Department of Physics, University of Liverpool, Liverpool, UK.
| | - B Goilav
- Department of Paediatric Nephrology, Albert Einstein College of Medicine, New York, USA.
| | | | - A Phuti
- Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa.
| | - T Rubinstein
- Department of Paediatric Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - D Wahezi
- Department of Paediatric Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - C A Jones
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - S D Marks
- Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
| | - R Corkhill
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK.
| | - C Pilkington
- Paediatric Rheumatology, Great Ormond Street Hospital, London, UK.
| | - K Tullus
- Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
| | - C Putterman
- Department of Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - C Scott
- Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa.
| | - A C Fisher
- Medical Physics and Clinical Engineering, and Department of Physics, University of Liverpool, Liverpool, UK.
| | - M W Beresford
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Smith EMD, Lewandowski LB, Jorgensen AL, Phuti A, Nourse P, Scott C, Beresford MW. Growing international evidence for urinary biomarker panels identifying lupus nephritis in children - verification within the South African Paediatric Lupus Cohort. Lupus 2018; 27:2190-2199. [PMID: 30348048 DOI: 10.1177/0961203318808376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A urinary biomarker panel including alpha-1-acid-glycoprotein (AGP), lipocalin-like-prostaglandin-D-synthase (LPGDS), transferrin and ceruloplasmin demonstrates an 'excellent' ability for identifying active lupus nephritis in UK/US children. This study aimed to assess whether this panel identifies active lupus nephritis within the South African Paediatric Lupus Cohort. METHODS Juvenile-onset-systemic lupus erythematosus (JSLE) patients aged < 19 years at diagnosis and healthy controls were recruited. Patients were categorized as having active lupus nephritis (renal BILAG score; A/B and previous histological confirmation) or inactive lupus nephritis (renal BILAG score: D/E). Urinary biomarkers were quantified by ELISA. Mann-Whitney U-test compared biomarker levels between groups. Binary logistic regression and receiver operating curve analysis assessed biomarker combinations. RESULTS Twenty-three juvenile-onset-systemic lupus erythematosus patients were recruited with a median age of 13.5 years (interquartile range (IQR) 12.7-14.9) and disease duration of 2.6 years (IQR 1.8-4.0). Eighteen healthy controls had a median age of 11.0 years (IQR 10.0-12.0). AGP, LPGDS, transferrin, ceruloplasmin and VCAM-1 were significantly higher in active than in inactive lupus nephritis patients (corrected p-values, all pc < 0.05), with no difference between inactive lupus nephritis patients and healthy controls (all pc = 1.0). The optimal biomarker combination included AGP, ceruloplasmin, LPGDS and transferrin (area under the curve = 1.0). CONCLUSIONS A urinary biomarker panel comprising AGP, ceruloplasmin, LPGDS and transferrin previously validated within UK/US cohorts also performed excellently within a racially distinct South African cohort which displayed more severe lupus nephritis.
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Affiliation(s)
- E M D Smith
- 1 Department of Women's & Children's Health, University of Liverpool, UK.,2 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - L B Lewandowski
- 3 Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA
| | - A L Jorgensen
- 4 Department of Biostatistics, University of Liverpool, UK
| | - A Phuti
- 5 Paediatric Rheumatology, University of Cape Town, South Africa
| | - P Nourse
- 6 Paediatric Nephrology, University of Cape Town, South Africa
| | - C Scott
- 5 Paediatric Rheumatology, University of Cape Town, South Africa
| | - M W Beresford
- 1 Department of Women's & Children's Health, University of Liverpool, UK.,2 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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13
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Mody PG, Mody GM, Assounga A. The clinical manifestations and response to treatment in South Africans with lupus nephritis. Lupus 2018; 27:1207-1217. [PMID: 29665754 DOI: 10.1177/0961203318770024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There are varying observations on the influence of ethnicity on the clinical spectrum and response to treatment in lupus nephritis (LN). We studied a multiethnic South African LN cohort to determine the clinical manifestations, histological involvement and response to therapy. We reviewed the records of LN patients at Inkosi Albert Luthuli Central Hospital in Durban. There were 105 patients, 92.5% females and they comprised 49.1% Indians and 45.3% African Blacks. The mean age was 31.3 ± 12.5 years, and 41.5% had LN at first presentation of lupus. The most common histological classes were Class V alone in 34.9%, Class IV (± Class V) in 25.5% and Class III (±Class V) in 22.6%. The estimated glomerular filtration rate was reduced (<30 ml/min) at presentation in 15 (14.2%). Eighty-seven patients received therapy for LN. A response to induction therapy was noted in 81.6% and maintenance therapy (12 months) in 73.6%. Response to mycophenolate mofetil (MMF) was 80.4% and 68.4% during induction and maintenance therapy, respectively. There was no ethnic difference in the histological class or response to MMF but African Blacks had more severe renal disease at presentation. In conclusion, our multiethnic LN cohort shows a high prevalence of membranous LN and good response to treatment.
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Affiliation(s)
- P G Mody
- 1 Department of Nephrology, School of Clinical Medicine, 72753 University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital , Durban, South Africa
| | - G M Mody
- 2 Department of Rheumatology, School of Clinical Medicine, 72753 University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital , Durban, South Africa
| | - A Assounga
- 1 Department of Nephrology, School of Clinical Medicine, 72753 University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital , Durban, South Africa
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14
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Wilson PC, Kashgarian M, Moeckel G. Interstitial inflammation and interstitial fibrosis and tubular atrophy predict renal survival in lupus nephritis. Clin Kidney J 2017; 11:207-218. [PMID: 29644061 PMCID: PMC5888814 DOI: 10.1093/ckj/sfx093] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/19/2017] [Indexed: 11/14/2022] Open
Abstract
Background This study examines the effect of interstitial inflammation and interstitial fibrosis and tubular atrophy on renal survival in lupus nephritis. Methods Baseline characteristics, initial (n = 301) and repeat biopsies (n = 94) and clinical outcomes for patients with biopsy-proven lupus nephritis from 1998 to 2014 were retrospectively collected from the medical record. Clinical and morphologic variables were evaluated using a Cox proportional hazards model and multiple imputation to address missing data. Renal survival was defined as the time from initial biopsy to end-stage renal disease [estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2], dialysis or transplant. Results A total of 218 patients had follow-up and Class IV had worse renal survival, especially in patients with active and chronic glomerular lesions {relative to non-IV; Class IV-A: hazard ratio [HR] 0.92 [95% confidence interval (CI) 0.41–2.04], Class IV-AC: HR 5.02 [95% CI 2.70–9.36]}. Interstitial inflammation grade [relative to interstitial inflammation <5%; interstitial inflammation 5–25%: HR 2.36 (95% CI 1.13–4.91), interstitial inflammation 25–50%: HR 3.84 (95% CI 1.53–9.62), interstitial inflammation >50%: HR 7.67 (95% CI 3.75–15.67)] and increased interstitial fibrosis and tubular atrophy (IFTA) category [relative to IFTA <5%; IFTA 5–25%: HR 3.93 (95% CI 1.58–9.75), IFTA 25–50%: HR 4.01 (95% CI 1.37–11.70), IFTA >50%: HR 13.99 (95% CI 4.91–39.83)] predicted worse renal survival among all patients and those with Class IV on initial and repeat biopsy (n = 94) in a dose-dependent manner. Interstitial inflammation grade and IFTA category were significant predictors of renal survival in a multivariable model adjusted for age, gender, race, ethnicity and serum creatinine. Conclusions Interstitial inflammation and IFTA independently affect renal survival and grading these lesions stratifies risk within the International Society of Nephrology and Renal Pathology Society classification of lupus nephritis.
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Affiliation(s)
- Parker C Wilson
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Kashgarian
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Gilbert Moeckel
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
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15
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Wolf BJ, Spainhour JC, Arthur JM, Janech MG, Petri M, Oates JC. Development of Biomarker Models to Predict Outcomes in Lupus Nephritis. Arthritis Rheumatol 2017; 68:1955-63. [PMID: 26867033 DOI: 10.1002/art.39623] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 02/02/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The American College of Rheumatology guidelines for the treatment of lupus nephritis recommend change in induction therapy when response to therapy has not occurred within 6 months. Response is not defined, and renal fibrosis can occur while waiting for this end point. Therefore, a decision support tool to better define response is needed to guide clinicians when starting patients on therapy. This study was undertaken to identify biomarker models with sufficient predictive power to develop such a tool. METHODS Urine samples from 140 patients with biopsy-proven lupus nephritis who had not yet started induction therapy were analyzed for a panel of urinary biomarkers. Univariate receiver operating characteristic (ROC) curves were generated for each individual biomarker and compared to the ROC area under the curve values from machine learning models developed using random forest algorithms. Biomarker models of outcome developed with novel markers in addition to clinical markers were compared to those developed with traditional clinical markers alone. RESULTS Models developed with the combined traditional and novel biomarker panels demonstrated clinically meaningful predictive power. Markers most predictive of response were chemokines, cytokines, and markers of cellular damage. CONCLUSION This is the first study to demonstrate the power of low-abundance biomarker panels and machine learning algorithms for predicting lupus nephritis outcomes. This is a critical first step in research to develop clinically meaningful decision support tools.
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Affiliation(s)
| | - John C Spainhour
- Medical University of South Carolina, Charleston (current address: Georgia Institute of Technology and Emory University, Atlanta, Georgia)
| | - John M Arthur
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston
| | - Michael G Janech
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jim C Oates
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston
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16
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Yu F, Haas M, Glassock R, Zhao MH. Redefining lupus nephritis: clinical implications of pathophysiologic subtypes. Nat Rev Nephrol 2017; 13:483-495. [PMID: 28669995 DOI: 10.1038/nrneph.2017.85] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic lupus erythematosus (SLE) is associated with a broad spectrum of clinical and immunologic manifestations, of which lupus nephritis is the most common cause of morbidity and mortality. The development of nephritis in patients with SLE involves multiple pathogenic pathways including aberrant apoptosis, autoantibody production, immune complex deposition and complement activation. The 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification system for lupus nephritis was widely accepted with high intraobserver and interobserver concordance to guide therapeutic strategy and provide prognostic information. However, this classification system is not based on the underlying disease pathophysiology. Some additional lesions that contribute to disease presentation, including glomerular crescents, podocyte injury, tubulointerstitial lesions and vascular injury, should be recognized. Although outcomes for patients with lupus nephritis have improved over the past 30 years, treatment of this disease remains challenging and is best approached on the basis of the underlying pathogenesis, which is only partially represented by the various pathological phenotypes defined by the ISN/RPS classification. Here, we discuss the heterogeneous mechanisms involved in the pathogenesis of lupus nephritis and how improved understanding of underlying disease mechanisms might help guide therapeutic strategies.
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Affiliation(s)
- Feng Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P. R. China.,Department of Nephrology, Peking University International Hospital, 1 Zhongguancun Life and Science Street, Changping District, Beijing 102206, P. R. China
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, 90048 California, USA
| | - Richard Glassock
- Department of Medicine, David Geffen School of Medicine at UCLA, 8 Bethany, Laguna Niguel, 92677 California, USA
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, P. R. China.,Peking-Tsinghua Center for Life Sciences, 5 Summer Palace Street, Haidian District, Beijing 100871, P. R. China
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17
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Rijnink EC, Teng YO, Wilhelmus S, Almekinders M, Wolterbeek R, Cransberg K, Bruijn JA, Bajema IM. Clinical and Histopathologic Characteristics Associated with Renal Outcomes in Lupus Nephritis. Clin J Am Soc Nephrol 2017; 12:734-743. [PMID: 28473317 PMCID: PMC5477219 DOI: 10.2215/cjn.10601016] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/01/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The prognostic significance of histopathologic (sub)classes in the current classification of lupus nephritis (LN) is controversial. We analyzed clinical and histopathologic predictors of renal outcome in LN outside the framework of the classification. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Variables (50 histopathologic and ten clinical) were tested in mixed, linear, and Cox regression models for their association with renal flare, ESRD, and eGFR during follow-up (1, 5, and 10 years) in 105 patients with LN who underwent biopsy from 1987 to 2011. The Cockcroft-Gault (normalized to a body surface area of 1.73 m2) and Schwartz formulas were used to calculate eGFR for adults and children, respectively. RESULTS During median follow-up of 9.9 years (25th-75th percentile, 5.9-13.8), 47 patients experienced a renal flare and 21 progressed to ESRD. Renal flare was predicted by fibrinoid necrosis (hazard ratio [HR], 1.04 per %; 95% confidence interval [95% CI], 1.00 to 1.07) and nonwhite race (HR, 2.23; 95% CI, 1.23 to 4.04). ESRD was predicted by fibrinoid necrosis (HR, 1.08 per %; 95% CI, 1.02 to 1.13), fibrous crescents (HR, 1.09 per %; 95% CI, 1.02 to 1.17), interstitial fibrosis/tubular atrophy (IF/TA) ≥25% (HR, 3.89; 95% CI, 1.25 to 12.14), eGFR at baseline (HR, 0.98 per ml/min per 1.73 m2; 95% CI, 0.97 to 1.00), and nonwhite race (HR, 7.16; 95% CI, 2.34 to 21.91). A higher mean eGFR during follow-up was associated with normal glomeruli (+0.2 ml/min per 1.73 m2 per %; 95% CI, 0.1 to 0.4). Like ESRD, a lower eGFR during follow-up was associated with fibrous crescents, IF/TA≥25%, and nonwhite race, as well as with cellular/fibrocellular crescents (-0.4 ml/min per 1.73 m2 per %; 95% CI, -0.6 to -0.2) and age (-0.8 ml/min per 1.73 m2 per year; 95% CI, -1.2 to -0.4). CONCLUSION The LN classification should include an index of evidence-based prognosticators. Awaiting validation of a formal index, we suggest that at least fibrinoid necrosis, fibrous crescents, and IF/TA warrant explicit independent scoring to assess the risk of progressive renal dysfunction in conjunction with clinical findings.
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Affiliation(s)
| | - Y.K. Onno Teng
- Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands; and
| | | | | | | | - Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus University Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands
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18
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Oni L, Beresford MW, Witte D, Chatzitolios A, Sebire N, Abulaban K, Shukla R, Ying J, Brunner HI. Inter-observer variability of the histological classification of lupus glomerulonephritis in children. Lupus 2017; 26:1205-1211. [PMID: 28478696 DOI: 10.1177/0961203317706558] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The gold standard for the classification of lupus nephritis is renal histology but reporting variation exists. The aim of this study was to assess the inter-observer variability of the 2003 International Society of Nephrology/Royal Pathology Society (ISN/RPS) lupus nephritis histological classification criteria in children. Histopathologists from a reference centre and three tertiary paediatric centres independently reviewed digitalized renal histology slides from 55 children with lupus nephritis. Histological ISN/RPS Class was assigned and features scored; lupus nephritis-activity [scored 0-24], lupus nephritis-chronicity [0-12] and tubulointerstitial activity [0-21]. In the cohort (73% females), the age at the time of biopsy was 15.5 ± 0.39 (mean ± standard error) years. Based on the reference centre, 42% (23/55) had ISN/RPS Class IV with lupus nephritis-activity score 4.23 ± 0.50, lupus nephritis-chronicity 1.81 ± 0.18 and tubulointerstitial activity 4.45 ± 0.35. There were 4-54 (mean 16.7) glomeruli per biopsy. Pathologists had fair agreement for ISN/RPS assignment (kappa; 0.26 ± 0.12), lupus nephritis-chronicity (intra-class correlation 0.36 ± 0.09) and tubulointerstitial activity (0.22 ± 0.09) scores. There was good agreement for lupus nephritis-activity scores (intra-class correlation 0.69 ± 0.06). When categorized into proliferative and non-proliferative disease, poor agreement among sites remained (kappa 0.24 ± 0.11). Despite unified criteria for the interpretation of histological features of lupus nephritis, marked reporting variation remains in clinical practice. As proliferative lupus nephritis is managed more intensively, this may influence renal outcomes.
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Affiliation(s)
- L Oni
- 1 Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.,2 Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M W Beresford
- 2 Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,3 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - D Witte
- 4 Department of Pediatric Histopathology, Cincinnati Children's Hospital Medical Centre, Cincinnati, USA
| | - A Chatzitolios
- 5 Department of Histopathology, Southmead Hospital, Bristol, UK
| | - N Sebire
- 6 Department of Paediatric Histopathology, Great Ormond Street Hospital, London, UK
| | - K Abulaban
- 7 Department of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Centre, Cincinnati, USA
| | - R Shukla
- 8 Department of Paediatric Histopathology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - J Ying
- 9 Centre for Biostatistical Services, University of Cincinnati College of Medicine, Cincinnati, USA
| | - H I Brunner
- 7 Department of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Centre, Cincinnati, USA
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19
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Restrepo-Escobar M, Granda-Carvajal PA, Jaimes F. Systematic review of the literature on reproducibility of the interpretation of renal biopsy in lupus nephritis. Lupus 2017; 26:1502-1512. [PMID: 28441914 DOI: 10.1177/0961203317706556] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Before using a test, it should be determined whether the results are reliable. The reliability of the interpretation of renal biopsy in patients with lupus nephritis has not been clearly elucidated. Our objective was to estimate inter and intra-observer reliability of the histological classification, as well as activity and chronicity indices in renal biopsy of patients with lupus nephritis. Methods We conducted a systematic search of the literature, which included articles in any language, using PubMed, Embase, Cochrane and Lilacs databases. Search terms included were: reproducibility, reliability, agreement, systemic lupus erythematosus and lupus nephritis. Comparative studies with any design were included, regardless of the year or the language of publication. Two investigators, independently, screened the literature published in accordance with pre-established inclusion and exclusion criteria. Results We found 13 relevant studies. Inter-observer reproducibility of most measurements was moderate or low, despite the fact that, in most cases, the readings were made by expert nephropathologists. There was great diversity among designs, participants, including samples and outcomes evaluated in different studies. Although there are too many reports on the clinical use, studies evaluating the reliability of classifications on renal biopsy in lupus nephritis are rare. The quality of the methodological design and reporting was fair. Conclusion The interpretation of renal biopsy in lupus nephritis is poorly reproducible, causing serious doubts about its validity and its clinical application. As it can lead to serious diagnosis, treatment and prognosis errors, it is necessary to intensify research in this field.
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Affiliation(s)
- M Restrepo-Escobar
- 1 Department of Internal Medicine and Rheumatology Research Group -GRUA-, Universidad de Antioquia. Division of Rheumatology, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P A Granda-Carvajal
- 2 Internal Medicine Department, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - F Jaimes
- 3 Department of Internal Medicine and Clinical Epidemiology Academic Research Group-GRAEPIC-, Universidad de Antioquia. Research Unit, Hospital Pablo Tobón Uribe. Medellín, Colombia
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20
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Barisoni L, Gimpel C, Kain R, Laurinavicius A, Bueno G, Zeng C, Liu Z, Schaefer F, Kretzler M, Holzman LB, Hewitt SM. Digital pathology imaging as a novel platform for standardization and globalization of quantitative nephropathology. Clin Kidney J 2017; 10:176-187. [PMID: 28584625 PMCID: PMC5455257 DOI: 10.1093/ckj/sfw129] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/01/2016] [Indexed: 12/16/2022] Open
Abstract
The introduction of digital pathology to nephrology provides a platform for the development of new methodologies and protocols for visual, morphometric and computer-aided assessment of renal biopsies. Application of digital imaging to pathology made substantial progress over the past decade; it is now in use for education, clinical trials and translational research. Digital pathology evolved as a valuable tool to generate comprehensive structural information in digital form, a key prerequisite for achieving precision pathology for computational biology. The application of this new technology on an international scale is driving novel methods for collaborations, providing unique opportunities but also challenges. Standardization of methods needs to be rigorously evaluated and applied at each step, from specimen processing to scanning, uploading into digital repositories, morphologic, morphometric and computer-aided assessment, data collection and analysis. In this review, we discuss the status and opportunities created by the application of digital imaging to precision nephropathology, and present a vision for the near future.
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Affiliation(s)
- Laura Barisoni
- Department of Pathology, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Charlotte Gimpel
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center – University of Freiburg, Germany
| | - Renate Kain
- Clinical Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Arvydas Laurinavicius
- Faculty of Medicine and National Center of Pathology, Vilnius University, Vilnius, Lithuania
| | - Gloria Bueno
- VISILAB – E.T.S.I.I., University of Castilla-La Mancha, Ciudad Real, Spain
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Franz Schaefer
- University Children Hospital, Pediatric Nephrology, Heidelberg, Germany
| | - Matthias Kretzler
- Department of Internal Medicine and Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Lawrence B. Holzman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen M. Hewitt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
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21
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Pagni F, Galimberti S, Galbiati E, Rebora P, Pietropaolo V, Pieruzzi F, Smith AJ, Ferrario F. Tubulointerstitial lesions in lupus nephritis: International multicentre study in a large cohort of patients with repeat biopsy. Nephrology (Carlton) 2016; 21:35-45. [PMID: 26132414 DOI: 10.1111/nep.12555] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The glomerulocentric International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification is the gold standard for the evaluation of lupus nephritis, while tubulointerstitial (TIN) parameters are often under-recognized in pathological reports. METHODS Renal biopsies from 142 patients who underwent repeat biopsy (RB) were evaluated for the following histological parameters: (i) inflammatory interstitial infiltrates; (ii) interstitial fibrosis; (iii) tubulitis; and (iv) tubular atrophy. The inter-relationships between the four TIN variables were explored by multivariate analysis. A linear mixed model was used to investigate the potential impact of TIN variables on eGFR and proteinuria at the two biopsy occasions. RESULTS The study showed that moderate-severe lesions were not so frequent at the reference biopsy, but more extensively represented upon RB. A strong association was found between the two inflammatory indices and between those related to chronic damage, while the relationship with the ISN/RPS classification was present at RB. If class IV-G was the most related with TIN (especially at RB), the existence of primary TIN in class II patients was also confirmed. Finally, our results support the hypothesis that tubulitis is an independent predictive factor for eGFR. CONCLUSIONS We recommend that the standard histological evaluation of SLE nephritis also includes TIN features.
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Affiliation(s)
- Fabio Pagni
- Department of Surgery and Translational Medicine, Pathology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Stefania Galimberti
- Department of Health Sciences, Center of Biostatistics for Clinical Epidemiology, University of Milano-Bicocca, Monza, Italy
| | | | - Paola Rebora
- Department of Health Sciences, Center of Biostatistics for Clinical Epidemiology, University of Milano-Bicocca, Monza, Italy
| | | | - Federico Pieruzzi
- Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Andrew James Smith
- Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Franco Ferrario
- Department of Pathology, Nephropathology Centre, University of Milano-Bicocca, Monza, Italy
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22
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Moroni G, Depetri F, Ponticelli C. Lupus nephritis: When and how often to biopsy and what does it mean? J Autoimmun 2016; 74:27-40. [PMID: 27349351 DOI: 10.1016/j.jaut.2016.06.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 01/30/2023]
Abstract
Renal disease is a frequent complication of SLE which can lead to significant illness and even death. Today, a baseline renal biopsy is highly recommended for all subjects with evidence of lupus nephritis. Biopsy allows the clinician to recognize and classify different forms of autoimmune lupus glomerulonephritis, and to detect other glomerular diseases with variable pathogenesis which are not directly related to autoimmune reactivity, such as lupus podocytopathy. Moreover, not only glomerular diseases, but other severe forms of renal involvement, such as tubulo-interstitial nephritis or thrombotic microangiopathy may be detected by biopsy in lupus patients. Thus, an accurate definition of the nature and severity of renal involvement is mandatory to assess the possible risk of progression and to establish an appropriate treatment. The indications to repeat biopsy are more controversial. Some physicians recommend protocol biopsies to recognize the possible transformation from one class to another one, or to identify silent progression of renal disease, others feel that good clinical monitoring is sufficient to assess prognosis and to make therapeutic decisions. At any rate, although any decision should always be taken by considering the clinical conditions of the patient, there are no doubts that repeat renal biopsy may represent a useful tool in difficult cases to evaluate the response to therapy, to modulate the intensity of treatment, and to predict the long-term renal outcome both in quiescent lupus and in flares of activity.
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Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milano, Italy.
| | - Federica Depetri
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milano, Italy.
| | - Claudio Ponticelli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
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Wilhelmus S, Alpers CE, Cook HT, Ferrario F, Fogo AB, Haas M, Joh K, Noël LH, Seshan SV, Bruijn JA, Bajema IM. The Revisited Classification of GN in SLE at 10 Years: Time to Re-Evaluate Histopathologic Lesions. J Am Soc Nephrol 2015; 26:2938-46. [PMID: 26152271 DOI: 10.1681/asn.2015040384] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/31/2015] [Indexed: 11/03/2022] Open
Abstract
Over 10 years have passed since the latest revision of the histopathologic classification of lupus nephritis. This revision was a significant improvement compared with the previous version, mainly because of clearer and more concise definitions and the elimination of mixed subclasses. Despite these improvements, there are still some difficulties in the classification for lupus nephritis, many of which are in the definitions provided. In this review, we focus on the difficulties surrounding the evaluation of classes III and IV lesions, particularly the definitions of endocapillary and extracapillary proliferation, the use of the terms endocapillary proliferation and hypercellularity, the clinical relevance of segmental and global subdivision in class IV, and the value of distinguishing lesions that indicate activity and chronicity. Vascular and tubulointerstitial lesions are also discussed. Furthermore, we give an overview of the history of the classification to provide background on the origin and development of the definitions in lupus nephritis. The issues raised in this review as well as the suggestions for improvements may assist with a revision of the lupus nephritis classification in the near future.
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Affiliation(s)
- Suzanne Wilhelmus
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands;
| | - Charles E Alpers
- Department of Pathology, University of Washington, Seattle, Washington
| | - H Terence Cook
- Department of Medicine, Centre for Complement and Inflammation Research, Imperial College London, London, United Kingdom
| | | | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Kensuke Joh
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Laure-Hélène Noël
- Department of Pathology, Necker Hospital, French National Institutes of Health and Medical Research, Paris, France; and
| | - Surya V Seshan
- Department of Pathology, Weill Cornell Medical College, New York, New York
| | - Jan A Bruijn
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
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Kiremitci S, Ensari A. Classifying lupus nephritis: an ongoing story. ScientificWorldJournal 2014; 2014:580620. [PMID: 25548784 PMCID: PMC4274910 DOI: 10.1155/2014/580620] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 11/13/2014] [Accepted: 11/14/2014] [Indexed: 11/17/2022] Open
Abstract
The role of the renal biopsy in lupus nephritis is to provide the diagnosis and to define the parameters of prognostic and therapeutic significance for an effective clinicopathological correlation. Various classification schemas initiated by World Health Organization in 1974 have been proposed until the most recent update by International Society of Nephrology/Renal Pathology Society in 2004. In this paper, we reviewed the new classification system with the associated literature to highlight the benefits and the weak points that emerged so far. The great advantage of the classification emerged to provide a uniform reporting for lupus nephritis all over the world. It has provided more reproducible results from different centers. However, the studies indicated that the presence of glomerular necrotizing lesion was no longer significant to determine the classes of lupus nephritis leading to loss of pathogenetic diversity of the classes. Another weakness of the classification that also emerged in time was the lack of discussions related to the prognostic significance of tubulointerstitial involvement which was not included in the classification. Therefore, the pathogenetic diversity of the classification still needs to be clarified by additional studies, and it needs to be improved by the inclusion of the tubulointerstitial lesions related to prognosis.
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Affiliation(s)
- Saba Kiremitci
- Pathology Department, Medical School of Ankara University, Sihhiye, 06100 Ankara, Turkey
| | - Arzu Ensari
- Pathology Department, Medical School of Ankara University, Sihhiye, 06100 Ankara, Turkey
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Al-Janabi S, Huisman A, Jonges GN, Ten Kate FJW, Goldschmeding R, van Diest PJ. Whole slide images for primary diagnostics of urinary system pathology: a feasibility study. J Renal Inj Prev 2014; 3:91-6. [PMID: 25610886 PMCID: PMC4301392 DOI: 10.12861/jrip.2014.26] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/28/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION During the last decade, whole slide images (WSI) have been used in many areas of pathology such as teaching, research, digital archiving, teleconsultation and quality assurance testing. However, WSI have as yet not much been used for upfront diagnostics because of the lack of validation studies. OBJECTIVES The aim of this study was to test the feasibility of WSI for primary diagnosis of urinary tract pathology. MATERIALS AND METHODS 100 consecutive urinary tract biopsies and resections which had been diagnosed conventionally between the years 2008-2009 were scanned at 20× magnification, and rediagnosed by two pathologists on WSI, having the original clinical information available, but blinded to the original diagnoses. Original and WSI diagnoses were compared and classified as concordant, slightly discordant (without clinical consequences) and discordant. RESULTS Original and WSI based rediagnosis were concordant in 87% of the cases. Original and WSI diagnosis were slightly discordant in 8% of cases. Major discrepancies with clinical or prognostic implications were founded in only 5 cases. However, for 6 out of the 13 discrepancies, WSI based diagnoses were considered to be better than the original diagnoses. CONCLUSION Primary diagnostics of urinary tract specimens can be reliably done on WSI. Further improvements of image resolution may help to increase diagnostic accuracy and WSI acceptance in routine pathology.
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Affiliation(s)
- Shaimaa Al-Janabi
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - André Huisman
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geertruida N Jonges
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fiebo J W Ten Kate
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roel Goldschmeding
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
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Wilhelmus S, Cook HT, Noël LH, Ferrario F, Wolterbeek R, Bruijn JA, Bajema IM. Interobserver agreement on histopathological lesions in class III or IV lupus nephritis. Clin J Am Soc Nephrol 2014; 10:47-53. [PMID: 25384443 DOI: 10.2215/cjn.03580414] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES To treat lupus nephritis effectively, proper identification of the histologic class is essential. Although the classification system for lupus nephritis is nearly 40 years old, remarkably few studies have investigated interobserver agreement. Interobserver agreement among nephropathologists was studied, particularly with respect to the recognition of class III/IV lupus nephritis lesions, and possible causes of disagreement were determined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A link to a survey containing pictures of 30 glomeruli was provided to all 360 members of the Renal Pathology Society; 34 responses were received from 12 countries (a response rate of 9.4%). The nephropathologist was asked whether glomerular lesions were present that would categorize the biopsy as class III/IV. If so, additional parameters were scored. To determine the interobserver agreement among the participants, κ or intraclass correlation values were calculated. The intraclass correlation or κ-value was also calculated for two separate levels of experience (specifically, nephropathologists who were new to the field or moderately experienced [less experienced] and nephropathologists who were highly experienced). RESULTS Intraclass correlation for the presence of a class III/IV lesion was 0.39 (poor). The κ/intraclass correlation values for the additional parameters were as follows: active, chronic, or both: 0.36; segmental versus global: 0.39; endocapillary proliferation: 0.46; influx of inflammatory cells: 0.32; swelling of endothelial cells: 0.46; extracapillary proliferation: 0.57; type of crescent: 0.46; and wire loops: 0.35. The highly experienced nephropathologists had significantly less interobserver variability compared with the less experienced nephropathologists (P=0.004). CONCLUSIONS There is generally poor agreement in terms of recognizing class III/IV lesions. Because experience clearly increases interobserver agreement, this agreement may be improved by training nephropathologists. These results also underscore the importance of a central review by experienced nephropathologists in clinical trials.
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Affiliation(s)
| | - H Terence Cook
- Department of Medicine, Imperial College, London, United Kingdom
| | - Laure-Hélène Noël
- Department of Pathology, Necker Hospital, French National Institute of Health and Medical Research (INSERM) U845, Paris, France; and
| | | | - Ron Wolterbeek
- Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Kidney diseases are morphologically heterogeneous. Pathologic classifications of renal disease permit standardization of diagnosis and may identify clinical-pathologic subgroups with different outcomes and/or responses to treatment. To date, classifications have been proposed for lupus nephritis, allograft rejection, IgA nephropathy, focal segmental glomerulosclerosis, antineutrophil cytoplasmic antibody -related glomerulonephritis, and diabetic glomerulosclerosis. These classifications share several limitations related to lack of specificity, reproducibility, validation, and relevance to clinical practice. They offer a standardized approach to diagnosis, however, which should facilitate communication and clinical research.
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Affiliation(s)
- M Barry Stokes
- Department of Pathology, Columbia University College of Physicians and Surgeons, 630 West 168th Street, VC14-224, New York, NY 10032, USA.
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Mubarak M, Nasri H. ISN/RPS 2003 classification of lupus nephritis: time to take a look on the achievements and limitations of the schema. J Nephropathol 2014; 3:87-90. [PMID: 25093155 PMCID: PMC4119328 DOI: 10.12860/jnp.2014.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 12/29/2013] [Indexed: 01/10/2023] Open
Abstract
Implication for health policy/practice/research/medical education:
Lupus nephritis (LN) is the most dreadful complication of systemic lupus erythematosus (SLE) and is responsible for the major share of morbidity and mortality of this disease. Its diagnosis, classification and management have posed significant challenges to the nephrologists and pathologists over the past several decades. A series of WHO classifications of LN were followed by the development of the international society of nephrology/renal pathology society (ISN/RPS) classification of LN in 2003. The classification has largely succeeded in achieving its goals, but a few limitations have also been exposed. It is time to revisit the classification in the light of experience of validation studies and new emerging data on this disease.
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Affiliation(s)
- Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan
| | - Hamid Nasri
- Department of Nephrology, Division of Nephropathology, Isfahan University of Medical Sciences, Isfahan, Iran
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Alaiya A, Assad L, Alkhafaji D, Shinwari Z, Almana H, Shoukri M, Alkorbi L, Ibrahim HG, Abdelsalam MS, Skolnik E, Adra C, Albaqumi M. Proteomic analysis of Class IV lupus nephritis. Nephrol Dial Transplant 2014; 30:62-70. [PMID: 24914093 DOI: 10.1093/ndt/gfu215] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There have been several attempts to standardize the definition and increase reproducibility in classifying lupus nephritis (LN). The last was made by the International Society of Nephrology and Renal Pathology Society in 2003 where the introduction of Class IV subcategories (global and segmental) was introduced. METHODS We investigated whether this subdivision is important using a proteomics approach. All patients with renal biopsies along with their clinical outcome of LN were identified and regrouped according to the above 2003 classifications. Fresh-frozen renal biopsies of Class IV LN (global and segmental), antineutrophil cytoplasmic antibody-associated vasculitis and normal tissue were analyzed using two-dimensional gel electrophoresis (2-DE) and mass spectrometry. Differentially expressed proteins were identified and subjected to principal component analysis (PCA), and post hoc analysis for the four sample groups. RESULTS PCA of 72 differentially expressed spots separated Class IV global and Class IV segmental from both normal and antineutrophil cytoplasmic antibody-associated vasculitis (ANCA). The 28 identified proteins were used in a post hoc analysis, and showed that IV-global and IV-segmental differ in several protein expression when compared with normal and ANCA. To confirm the proteomic results, a total of 78 patients (50 Class IV-Global and 28 Class IV-Segmental) were re-classified according to 2003 classification. There was no difference in therapy between the groups. The renal survival and patient survivals were similar in both groups. CONCLUSIONS There is no strong evidence to support a different outcome between the two subcategories of Class-IV LN and, they should thus be treated the same until further studies indicate otherwise.
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Affiliation(s)
- Ayodele Alaiya
- Proteomics Unit, Stem Cell and Tissue Re-Engineering Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Lina Assad
- Department of Pathology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dania Alkhafaji
- Nephrology Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Zakia Shinwari
- Proteomics Unit, Stem Cell and Tissue Re-Engineering Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hadeel Almana
- Department of Pathology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed Shoukri
- Department of Biostatistics and Epidemiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Lutfi Alkorbi
- Nephrology Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hossamaldin Galal Ibrahim
- Nephrology Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohamed Said Abdelsalam
- Nephrology Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia Internal Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Edward Skolnik
- Nephrology Division, Department of Medicine, New York University Medical Center, NY, USA
| | - Chaker Adra
- Proteomics Unit, Stem Cell and Tissue Re-Engineering Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia Transplantation Research Center, Renal Division, Children's Hospital Boston and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mamdouh Albaqumi
- Proteomics Unit, Stem Cell and Tissue Re-Engineering Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia Nephrology Section, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia Nephrology Division, Department of Medicine, New York University Medical Center, NY, USA Nephrology Section, Department of Medicine, MBC-46, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Sarhane KA, Tuffaha SH, Broyles JM, Ibrahim AE, Khalifian S, Baltodano P, Santiago GF, Alrakan M, Ibrahim Z. A critical analysis of rejection in vascularized composite allotransplantation: clinical, cellular and molecular aspects, current challenges, and novel concepts. Front Immunol 2013; 4:406. [PMID: 24324470 PMCID: PMC3839257 DOI: 10.3389/fimmu.2013.00406] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 11/08/2013] [Indexed: 12/17/2022] Open
Abstract
Advances in microsurgical techniques and immunomodulatory protocols have contributed to the expansion of vascularized composite allotransplantation (VCA) with very encouraging immunological, functional, and cosmetic results. Rejection remains however a major hurdle that portends serious threats to recipients. Rejection features in VCA have been described in a number of studies, and an international consensus on the classification of rejection was established. Unfortunately, current available diagnostic methods carry many shortcomings that, in certain cases, pose a great diagnostic challenge to physicians especially in borderline rejection cases. In this review, we revisit the features of acute skin rejection in hand and face transplantation at the clinical, cellular, and molecular levels. The multiple challenges in diagnosing rejection and in defining chronic and antibody-mediated rejection in VCA are then presented, and we finish by analyzing current research directions and novel concepts aiming at improving available diagnostic measures.
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Affiliation(s)
- Karim A Sarhane
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Haas M, Rastaldi MP, Fervenza FC. Histologic classification of glomerular diseases: clinicopathologic correlations, limitations exposed by validation studies, and suggestions for modification. Kidney Int 2013; 85:779-93. [PMID: 24088958 DOI: 10.1038/ki.2013.375] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 12/16/2022]
Abstract
The value of classification systems applied to the examination of renal biopsies is based on several factors: first, on the ability to provide efficient communication between pathologists and between pathologists and clinicians; second, on the possibility to implement diagnostic information with prognostic indication. Even more important, the practical value of a classification is proved by the ability of providing elements that guide therapeutic decisions and can be used in the follow-up of the patient. With these aims, new histologic classification systems have been proposed in the last decade for lupus nephritis and IgA nephropathy under the leadership of the Renal Pathology Society and the International Society of Nephrology. These classifications have gained a significant level of worldwide acceptance and have been the subject of multiple single-center and multicenter validation studies, which have underpinned their clinical benefits and limitations and served to highlight remaining questions and difficulties of interpretation of the biopsy sample. More recently, a classification system has also been proposed for ANCA-associated crescentic glomerulonephritis (ANCA-GN), although the validation process for this is still in an early stage. In this review, we examine in some detail the ISN/RPS classification for lupus nephritis and the Oxford classification for IgA nephropathy, with emphasis on clinicopathologic correlations, their value for and evolving impact on clinical studies and clinical practice, and their significant limitations in this regard as exposed by validation studies. We also suggest possible ways by which these classifications might be modified to make them more applicable to clinical practice. Finally, we more briefly discuss the newly proposed classification for ANCA-GN.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maria P Rastaldi
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione D'Amico per la Ricerca sulle Malattie Renali, Milano, Italy
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Pagni F, Galimberti S, Goffredo P, Basciu M, Malachina S, Pilla D, Galbiati E, Ferrario F. The value of repeat biopsy in the management of lupus nephritis: an international multicentre study in a large cohort of patients. Nephrol Dial Transplant 2013; 28:3014-23. [PMID: 23975838 DOI: 10.1093/ndt/gft272] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification represents the gold standard for the histological evaluation of Systemic Lupus Erythematosus (SLE) nephritis. A repeat biopsy (RB) might be an important tool to provide information on long-term renal outcomes and optimal therapy. Aims of this study were to evaluate the use of the ISN/RPS classification and the role of RB in routine clinical practice. METHODS A total number of 142 patients with SLE nephritis and with adequate reference and RB samples were included in this multicentre retrospective study. A meticulous histological examination was centrally performed on first and RB and compared with clinical variables and follow-up data. RESULTS Morphological features of the ISN/RPS classification: at first and RB, significant differences were observed between segmental classes (III, IV-S) and Class IV-G in mesangial proliferation, wire loops and tuft necrosis. Clinical features and ISN/RPS classification: the correlation between serum creatinine, proteinuria, blood pressure levels and histological classes at first and RB demonstrated more severe renal disease in Class IV-G, both at first and RB. Agreement between ISN/RPS classification at first and RB: 40.8% of patients changed the histological class. Fifty per cent of Class II (mild mesangial form) were reclassified as Class IV-G at RB, whereas 18.9% of Class IV-G were reclassified as Class II. The transition among segmental (III/IV-S) and mesangial forms (II/IV-G) was extremely rare. The comparison between the clinical parameters at the final follow-up and the ISN/RPS classification confirmed that the trend of serum creatinine and proteinuria between the different classes was better described at the RB (higher in Class IV-G) than on the first biopsy. CONCLUSIONS The histopathological data suggest that morphological differences between segmental and global forms do exist, possibly due to different pathogenetic mechanisms. An RB strategy could provide additional information on long-term renal outcomes. A strategy of protocol biopsies could be useful in perspective future trials to better understand the therapeutic response and the natural history of this disease.
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Affiliation(s)
- Fabio Pagni
- Department of Pathology, University Milano Bicocca, San Gerardo Hospital, Monza, Italy
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Nived O, Hallengren CS, Alm P, Jönsen A, Sturfelt G, Bengtsson AA. An observational study of outcome in SLE patients with biopsy-verified glomerulonephritis between 1986 and 2004 in a defined area of Southern Sweden: the clinical utility of the ACR renal response criteria and predictors for renal outcome. Scand J Rheumatol 2013; 42:383-9. [DOI: 10.3109/03009742.2013.799224] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Meehan SM, Chang A, Gibson IW, Kim L, Kambham N, Laszik Z. A study of interobserver reproducibility of morphologic lesions of focal segmental glomerulosclerosis. Virchows Arch 2012; 462:229-37. [PMID: 23262784 DOI: 10.1007/s00428-012-1355-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 11/21/2012] [Accepted: 11/29/2012] [Indexed: 11/26/2022]
Abstract
The morphology of focal segmental glomerulosclerosis (FSGS) includes collapsing, cellular, and sclerosing forms. The Columbia Working Classification of FSGS divides these into collapsing (COLL), cellular (CELL), tip lesion (TIP), perihilar (PH), and not otherwise specified (NOS) morphologic forms. This study examined the ability of renal pathologists to classify FSGS using single light microscopic images of glomeruli as a uniform data set. Sixty-one digital images of individual glomeruli with FSGS, stained by periodic acid-Schiff or Jones methenamine silver methods, were classified independently by six specialist renal pathologists. Diagnostic consistency was quantified using the kappa statistic for nominal categories. Agreement for 366 diagnoses by six observers was 75.2 % with a kappa value of 0.676. Six of six observers agreed in 31 of 61 cases (50.8 %) and four or more in 53 cases (86.9 %). Respective kappa values ranged from moderate to good: COLL 0.77, CELL 0.53, TIP 0.76, PH 0.84, and NOS 0.60. Capillary retraction with lobular expansion, hypercellularity, and sclerosis in the same glomerular segments, and the location of segmental lesions were sources of diagnostic inconsistency. The morphologic forms of FSGS defined by the Columbia system are reproducible between observers and have a low probability of confusion between forms. Individual glomeruli may have overlapping features of more than one form of FSGS.
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Affiliation(s)
- Shane M Meehan
- Department of Pathology, University of Chicago, 5841 South Maryland Ave, Chicago, IL 60637, USA.
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Torabinejad S, Mardani R, Habibagahi Z, Roozbeh J, Khajedehi P, Pakfetrat M, Banihashemi MA, Banihashemi SJ. Urinary monocyte chemotactic protein-1 and transforming growth factor-β in systemic lupus erythematosus. Indian J Nephrol 2012; 22:5-12. [PMID: 22279336 PMCID: PMC3263065 DOI: 10.4103/0971-4065.91179] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purpose of this investigation was to assess the correlation of two biomarkers with the occurrence of renal flares in systemic lupus erythematosus (SLE). Urine levels of monocyte chemotactic protein-1 (MCP-1) and transforming growth factor beta (TGF-β) were measured at baseline, and at two and four months in five groups of patients: 25 lupus nephritis patients with active disease (active LN), 10 lupus nephritis patients with SLE in remission (remission LN), 25 patients with clinical active SLE and without nephritis (active NLN), 10 patients without nephritis with SLE in remission (remission NLN) and 10 healthy controls. We used repeated measurement and ANOVA with Duncan's post hoc to analyze the data; the urine level of the two proteins could distinguish the groups based on the existence of lupus nephritis and/or activity of SLE disease. Furthermore we performed receiver operating curve analysis to identify a cutoff point with a good sensitivity and specificity to diagnose lupus nephritis with either one of the urine proteins. Finally the samples from active LN were grouped according to whether they were Class IV or other classes. Baseline urinary MCP-1, but not TGF-β, was significantly different between the classes. Further investigation into the use of these cytokines in a prospective study is needed to determine their capacity as diagnostic tools for renal flares.
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Affiliation(s)
- S Torabinejad
- Shiraz Nephrology Urology Research Center, Zand Avenue, Shiraz, Iran
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Giannico G, Fogo AB. Lupus Nephritis: Is the Kidney Biopsy Currently Necessary in the Management of Lupus Nephritis? Clin J Am Soc Nephrol 2012; 8:138-45. [DOI: 10.2215/cjn.03400412] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bertsias GK, Tektonidou M, Amoura Z, Aringer M, Bajema I, Berden JHM, Boletis J, Cervera R, Dörner T, Doria A, Ferrario F, Floege J, Houssiau FA, Ioannidis JPA, Isenberg DA, Kallenberg CGM, Lightstone L, Marks SD, Martini A, Moroni G, Neumann I, Praga M, Schneider M, Starra A, Tesar V, Vasconcelos C, van Vollenhoven RF, Zakharova H, Haubitz M, Gordon C, Jayne D, Boumpas DT. Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis 2012; 71:1771-82. [PMID: 22851469 PMCID: PMC3465859 DOI: 10.1136/annrheumdis-2012-201940] [Citation(s) in RCA: 671] [Impact Index Per Article: 55.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop recommendations for the management of adult and paediatric lupus nephritis (LN). METHODS The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus. RESULTS Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults. CONCLUSIONS Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- George K Bertsias
- Department of Medicine, Rheumatology, Clinical Immunology and Allergy, University of Crete, Iraklion, Greece
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Bellur SS, Troyanov S, Cook HT, Roberts IS. Reply. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Okpechi IG, Swanepoel CR, Tiffin N, Duffield M, Rayner BL. Clinicopathological insights into lupus nephritis in South Africans: a study of 251 patients. Lupus 2012; 21:1017-24. [DOI: 10.1177/0961203312441981] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are few published studies on biopsy proven lupus nephritis (LN) from sub-Sahara Africa, mainly due to lack of expertise and pathology back-up for performing and interpreting renal biopsies in many centres. The purpose of this study was to document factors associated with biopsy proven LN and to determine clinical and laboratory models that best predict proliferative LN in South Africans. Of the 251 patients studied, 84.1% were females and 79.3% were of mixed ancestry. There were more observed cases of proliferative LN (63%) than non-proliferative LN. Factors associated with proliferative LN were male gender ( p = 0.049), haematuria on dipstix ( p < 0.0001), proteinuria on dipstix ( p = 0.042), low serum albumin ( p = 0.032), low complement C3 ( p < 0.0001), low complement C4 ( p = 0.009) and positive double-stranded DNA ( p = 0.039). Using four models designed from various combinations of the factors associated with proliferative LN, the specificity and positive predictive values were highest for the model that combined gender (male), presence of dipstix haematuria and proteinuria, hypoalbuminaemia, low C3 and low C4 and positive double-stranded DNA (100% respectively). Further study is recommended to identify the value of using these demographic and laboratory parameters in identifying patients with proliferative LN in resource limited centres where the performance of a biopsy is not possible.
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Affiliation(s)
- IG Okpechi
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, South Africa
| | - CR Swanepoel
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, South Africa
| | - N Tiffin
- South African National Bioinformatics Institute, University of the Western Cape, South Africa
| | - M Duffield
- Department of Anatomical Pathology, University of Cape Town, South Africa
| | - BL Rayner
- Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, South Africa
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Haring CM, Rietveld A, van den Brand JAJG, Berden JHM. Segmental and global subclasses of class IV lupus nephritis have similar renal outcomes. J Am Soc Nephrol 2011; 23:149-54. [PMID: 22034639 DOI: 10.1681/asn.2011060558] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Whether renal outcomes differ between the segmental and global subclasses of diffuse proliferative (class IV) lupus nephritis is unknown. In this meta-analysis, we searched the literature in MEDLINE, EMBASE, five registries of clinical trials, and selected cohort studies and randomized, controlled trials that used the 2003 International Society of Nephrology and Renal Pathology Society classification of lupus nephritis in adult patients. Our endpoint was the composite of doubling of serum creatinine concentration or ESRD. In the eight studies included in the final analysis, the incidence of this endpoint varied between 0% and 67%. A funnel plot and Egger's test did not suggest significant heterogeneity. The meta-analysis did not support a significant difference in renal outcome between the segmental (IV-S) and global (IV-G) subclasses (relative risk for class IV-G versus IV-S, 1.08; 95% confidence interval, 0.68-1.70). Meta-regression did not suggest that ethnicity or duration of follow-up influenced the association between histologic class and renal risk. In conclusion, the rate of doubling of serum creatinine concentration or of ESRD did not differ between patients with class IV-S and those with IV-G lupus nephritis.
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Affiliation(s)
- Catharina M Haring
- Department of Nephrology, Radboud University, Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Abstract
Lupus nephritis is a major cause of morbidity and mortality in patients with systemic lupus erythematosus. The general consensus is that 60% of lupus patients will develop clinically relevant nephritis at some time in the course of their illness. Prompt recognition and treatment of renal disease is important, as early response to therapy is correlated with better outcome. The present review summarizes our current understanding of the pathogenic mechanisms underlying lupus nephritis and how the disease is currently diagnosed and treated.
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Affiliation(s)
- Ramesh Saxena
- Department of Internal Medicine, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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ISN/RPS 2003 class II mesangial proliferative lupus nephritis: a comparison between cases that progressed to class III or IV and cases that did not. Rheumatol Int 2011; 32:2459-64. [PMID: 21769491 DOI: 10.1007/s00296-011-1986-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 07/03/2011] [Indexed: 10/18/2022]
Abstract
Lupus nephritis (LN) class II has generally been considered a mild form of LN with a good response to treatment. Although the number was small, there have also been reports on later progression to class III or IV, resulting in poor renal and patient outcome. This study aims to review cases of LN class II to analyze differences between cases that progressed to class III or IV and cases that did not. We retrospectively analyzed 15 cases of LN class II among 277 cases of biopsy-proven lupus nephritis diagnosed in a tertiary medical center over about 14 years. Among the 15 patients, 5 patients progressed to class III or IV. Biopsy specimens were reviewed by a pathologist according to the ISN/RPS 2003 classification. Response to treatment was evaluated at 6 months after treatment. On fluorescence microscopy (IF), there was significantly higher degree of deposition in the glomeruli of IgM, IgA and C4 in the progression group than in the non-progression group. At 6 months after treatment, there was a trend toward higher rates of complete remission in the non-progression group (90%) compared with those in the progression group (40%, p = 0.077). Five of the 15 cases of ISN/RPS 2003 class II glomerulonephritis progressed to class III or IV over a mean of 5 years. The degree of immune-complex deposition for IgM, IgA and C4 in the glomeruli was significantly higher in the progression group.
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Abstract
Lupus nephritis is a complication of systemic lupus erythematosus, which has significant morbidity and mortality. The accepted standard of treatment for severe lupus nephritis is cyclophosphamide for induction of remission. This has significant adverse effects including severe infection and amenorrhea. In addition, although cyclophosphamide induces remission, long-term mortality does not seem to be altered. Mycophenolate mofetil (MMF) is an immunosuppressive agent originally used in solid organ transplantation, which has been compared with cyclophosphamide in trials for lupus nephritis. Randomized trials with MMF have been relatively small, although pooled data seem to suggest that it is at least as effective as cyclophosphamide in inducing remission. In addition, MMF has also been associated with a reduced risk of infection and amenorrhea, although this finding is not universal. MMF appears to be associated with more diarrhea compared with cyclophosphamide. MMF is likely to be a useful treatment for lupus nephritis, although available trial data are limited due to the small size of previous studies. A large trial (the Aspreva Lupus Management Study) is currently underway to attempt to establish the place of MMF in treatment of lupus nephritis.
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Clinicopathological insights into lupus glomerulonephritis in Japanese and Asians. Clin Exp Nephrol 2011; 15:321-330. [DOI: 10.1007/s10157-011-0434-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Accepted: 02/28/2011] [Indexed: 02/03/2023]
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Herzenberg AM, Fogo AB, Reich HN, Troyanov S, Bavbek N, Massat AE, Hunley TE, Hladunewich MA, Julian BA, Fervenza FC, Cattran DC. Validation of the Oxford classification of IgA nephropathy. Kidney Int 2011; 80:310-7. [PMID: 21544062 DOI: 10.1038/ki.2011.126] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The Oxford classification of IgA nephropathy (IgAN) identified four pathological elements that were of prognostic value and additive to known clinical and laboratory variables in predicting patient outcome. These features are segmental glomerulosclerosis/adhesion, mesangial hypercellularity, endocapillary proliferation, and tubular atrophy/interstitial fibrosis. Here, we tested the Oxford results using an independent cohort of 187 adults and children with IgAN from 4 centers in North America by comparing the performance of the logistic regression model and the predictive value of each of the four lesions in both data sets. The cohorts had similar clinical and histological findings, presentations, and clinicopathological correlations. During follow-up, however, the North American cohort received more immunosuppressive and antihypertensive therapies. Identifying patients with a rapid decline in the rate of renal function using the logistic model from the original study in the validation data set was good (c-statistic 0.75), although less precise than in the original study (0.82). Individually, each pathological variable offered the same predictive value in both cohorts except mesangial hypercellularity, which was a weaker predictor. Thus, this North American cohort validated the Oxford IgAN classification and supports its utilization. Further studies are needed to determine the relationship to the impact of treatment and to define the value of the mesangial hypercellularity score.
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Affiliation(s)
- Andrew M Herzenberg
- Division of Nephrology, Toronto General Hospital, University of Toronto, Ontario, Canada
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Abstract
Proliferative lupus nephritis is the most severe form of lupus nephritis. Outcomes of this disease are affected by ethnicity, clinical characteristics, irreversible damage on renal biopsy, initial response to treatment and future disease course (for example, the occurrence of renal flares). Initial intensive (induction) treatment of proliferative lupus nephritis is aimed at achieving remission, but optimal duration and intensity are not well defined. A combination of intravenous cyclophosphamide and corticosteroids have been shown to decrease the risk of end-stage renal disease, but are associated with substantial acute toxic effects (such as infections) and chronic toxic effects (such as ovarian failure). In white populations, low-dose cyclophosphamide is a reasonable alternative to high-dose cyclophosphamide as it is similarly effective and associated with less toxicity. Mycophenolate mofetil is as effective as high-dose intravenous cyclophosphamide in terms of inducing remission and similar in terms of safety. Although most patients respond to induction treatment, remission is often only achieved after patients are switched to maintenance treatment. As maintenance treatment, mycophenolate mofetil is superior to azathioprine and azathioprine is similarly effective to ciclosporin in terms of prevention or reducing the risk of relapse. Rituximab should be reserved for patients with refractory disease. Treatment of lupus nephritis should be individually tailored to patients, with more aggressive therapy reserved for patients at high risk of renal dysfunction and progression of renal disease.
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