Rapidly progressive crescentic diabetic nephropathy: two case reports

Glomerular crescents are associated with the risk of type 2 diabetic kidney disease progression: a retrospective cohort study

BACKGROUND

Diabetic kidney disease (DKD) stands as the predominant cause of chronic kidney disease and end-stage kidney disease. Its diverse range of manifestations complicates the treatment approach for patients. Although kidney biopsy is considered the gold standard for diagnosis, it lacks precision in predicting the progression of kidney dysfunction. Herein, we addressed whether the presence of glomerular crescents is linked to the outcomes in patients with biopsy-confirmed type 2 DKD.

METHODS

We performed a retrospective evaluation, involving 327 patients diagnosed with biopsy-confirmed DKD in the context of type 2 diabetes, excluding cases with other glomerular diseases, from nine tertiary hospitals. Hazard ratios (HRs) were calculated using a Cox regression model to assess the risk of kidney disease progression, defined as either ≥ 50% decrease in estimated glomerular filtration rates or the development of end-stage kidney disease, based on the presence of glomerular crescents.

RESULTS

Out of the 327 patients selected, ten patients had glomerular crescents observed in their biopsied tissues. Over the follow-up period (median of 19 months, with a maximum of 18 years), the crescent group exhibited a higher risk of kidney disease progression than the no crescent group, with an adjusted HR of 2.82 (1.32-6.06) (P = 0.008). The presence of heavy proteinuria was associated with an increased risk of developing glomerular crescents.

CONCLUSION

The presence of glomerular crescents is indeed linked to the progression of type 2 DKD. Therefore, it is important to determine whether there is an additional immune-mediated glomerulonephritis requiring immunomodulation, and it may be prudent to monitor the histology and repeat a biopsy.

[Non-Classical Clinical Types and Pathological Changes of Diabetic Kidney Disease: A Review]

Diabetic kidney disease (DKD) is a common complication of diabetes mellitus and approximately 1/3 of diabetic patients may progress to DKD. A typical early clinical manifestation of DKD is microalbuminuria and patients may present with macroproteinuria accompanied by a decrease in renal function condition as the disease progresses. It is generally believed that the likelihood of a reversal of the disease is reduced after the development of macroproteinuria in patients with DKD, and that eventually some patients' condition may develop into end-stage renal disease (ESRD). Moreover, the thickening of the glomerular basement membrane, mesangial matrix expansion, Kimmelstiel-Wilson (K-W) nodules, and glomerulosclerosis in end-stage diabetes mellitus are typical pathologic changes of DKD. However, some DKD patients, especially those with type 2 diabetes mellitus (T2DM) combined with DKD, may have diverse clinical manifestations, showing variations in disease progression and regression, and manifesting as non-classical types of DKD, such as normoalbuminuric DKD, proteinuria-reduced DKD, and DKD with rapid decline in renal function. In addition, the formation of crescents, a special pathological change, is observed in renal biopsy. However, this issue is currently under-recognized by clinicians and therefore deserves more attention. In order to improve clinicians' understanding of the presentations and pathological changes of non-classical DKD and the level of DKD prevention and treatment in China, we present a preliminary introduction to the clinical phenotypes and pathological changes of non-classical types of DKD in this paper by summarizing the findings of our prior studies as well as domestic and international literature.

Diabetic nephropathy with marked extra-capillary cell proliferation: a case report

BACKGROUND

Extra-capillary hypercellularity is a common finding in crescentic glomerulonephritis (GN) and focal segmental glomerulosclerosis (FSGS). In diabetic nephropathy (DN), extra-capillary hypercellularity is often observed as a finding of complications such as IgA nephropathy or microscopic polyangiitis superimposed on DN. However, in rare cases, epithelial cell proliferation may accompany DN. We experienced a case of nodular diabetic glomerulosclerosis with marked extra-capillary hypercellularity and revealed the origin of this atypical lesion using immunostainings.

CASE PRESENTATION

A man in his 50 s was admitted to the hospital with nephrotic syndrome, and a renal biopsy was performed. Diffuse nodular lesions and extra-capillary hypercellularity were observed, but the results of serological examination or immunofluorescent assays did not implicate any other crescentic GN. Immunostaining for claudin-1 and nephrin was performed to identify the origin of the extra-capillary lesions. Given the clinical course and pathological findings, a diagnosis of DN-associated extra-capillary cell proliferation was made.

CONCLUSIONS

Extra-capillary hypercellularity, which resembles FSGS or crescentic GN, is a rare finding in DN and should therefore be treated with caution. In such cases, co-staining for claudin-1 and nephrin may facilitate the diagnosis of DN.

Crescents, an Independent Risk Factor for the Progression of Type 2 Diabetic Kidney Disease

CONTEXT

Crescents have been noticed in pathologic changes in patients with diabetic kidney disease (DKD). However, the clinical significance of crescents is still not well recognized.

OBJECTIVE

The main objective was to investigate the association between crescents and the prognoses of type 2 DKD (T2DKD) patients, and, secondly, to analyze the relationship between crescents and clinicopathologic features.

METHODS

A retrospective cohort study of 155 patients with T2DKD diagnosed by renal biopsy was carried out in a single center. Clinicopathologic features of patients with or without crescents were analyzed. Cox regression models and meta-analysis were used to determine the prognostic values of crescents for T2DKD. A nomogram was constructed to provide a simple estimation method of 1, 3, and 5-year renal survival for patients with T2DKD.

RESULTS

Compared with T2DKD patients without crescents, patients with crescents had higher 24-hour proteinuria and serum creatinine levels, as well as more severe Kimmelstiel-Wilson (K-W) nodules, segmental sclerosis (SS), and mesangiolysis (all P < .05). Furthermore, the crescents were positively correlated with serum creatinine, 24-hour proteinuria, K-W nodules, SS, mesangiolysis, and complement 3 deposition. Multivariate Cox models showed that crescents were an independent prognostic risk factor for renal survival (hazard ratio [HR] 2.68, 95% CI 1.27-5.64). The meta-analyzed results of 4 studies on crescents in T2DKD confirmed that patients with crescents had a significantly higher HR for renal progression.

CONCLUSION

Patients with crescents in T2DKD have more severe clinicopathologic changes and worse prognoses. The crescent can serve as an independent risk factor for T2DKD progression.