1
|
Yano Y, Nagasu H, Kanegae H, Nangaku M, Hirakawa Y, Sugawara Y, Nakagawa N, Wada J, Sugiyama H, Nakano T, Wada T, Shimizu M, Suzuki H, Komatsu H, Nakashima N, Kitaoka K, Narita I, Okada H, Suzuki Y, Kashihara N. Kidney outcomes associated with haematuria and proteinuria trajectories among patients with IgA nephropathy in real-world clinical practice: The Japan Chronic Kidney Disease Database. Nephrology (Carlton) 2024; 29:65-75. [PMID: 37871587 DOI: 10.1111/nep.14250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/01/2023] [Accepted: 10/04/2023] [Indexed: 10/25/2023]
Abstract
AIM Among patients with Immunoglobulin A (IgA) nephropathy, we aimed to identify trajectory patterns stratified by the magnitude of haematuria and proteinuria using repeated urine dipstick tests, and assess whether the trajectories were associated with kidney events. METHODS Using a nationwide multicentre chronic kidney disease (CKD) registry, we analysed data from 889 patients with IgA nephropathy (mean age 49.3 years). The primary outcome was a sustained reduction in eGFR of 50% or more from the index date and thereafter. During follow-up (median 49.0 months), we identified four trajectories (low-stable, moderate-decreasing, moderate-stable, and high-stable) in both urine dipstick haematuria and proteinuria measurements, respectively. RESULTS In haematuria trajectory analyses, compared to the low-stable group, the adjusted hazard ratios (HRs) (95% confidence interval [CI]) for kidney events were 2.59 (95% CI, 1.48-4.51) for the high-stable, 2.31 (95% CI, 1.19-4.50) for the moderate-stable, and 1.43 (95% CI, (0.72-2.82) for the moderate-decreasing groups, respectively. When each proteinuria trajectory group was subcategorized according to haematuria trajectories, the proteinuria group with high-stable and with modest-stable haematuria trajectories had approximately 2-times higher risk for eGFR reduction ≥50% compared to that with low-stable haematuria trajectory. CONCLUSION Assessments of both haematuria and proteinuria trajectories using urine dipstick could identify high-risk IgA nephropathy patients.
Collapse
Affiliation(s)
- Yuichiro Yano
- Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina, USA
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroshi Kanegae
- Office of Research and Analysis, Genki Plaza Medical Center for Health Care, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yosuke Hirakawa
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yuka Sugawara
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Miho Shimizu
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Hitoshi Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiroyuki Komatsu
- Center for Medical Education and Career Development, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Naoki Nakashima
- Medical Information Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kaori Kitaoka
- Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| |
Collapse
|
2
|
Zand L, Fervenza FC, Coppo R. Microscopic hematuria as a risk factor for IgAN progression: considering this biomarker in selecting and monitoring patients. Clin Kidney J 2023; 16:ii19-ii27. [PMID: 38053974 PMCID: PMC10695511 DOI: 10.1093/ckj/sfad232] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Indexed: 12/07/2023] Open
Abstract
Hematuria-either macroscopic hematuria or asymptomatic microscopic hematuria-is a clinical feature typical but not specific for immunoglobulin A nephropathy (IgAN). The only biomarker supported by the Kidney Disease: Improving Global Outcomes group as a predictor of progression, identifying patients needing treatment, is proteinuria >1 g/day persistent despite maximized supportive care. However, proteinuria can occur in the setting of active glomerulonephritis or secondary to sclerotic renal lesions. Microscopic hematuria is observed in experimental models of IgAN after IgA-IgG immunocomplex deposition, activation of inflammation and complement pathways. Oxidative damage, triggered by hemoglobin release, is thought to contribute to the development of proteinuria and progression. Despite being a clinical hallmark of IgAN and having a rational relationship with its pathophysiology, the value of microscopic hematuria in assessing activity and predicting outcomes in patients with IgAN is still debated. This was partly due to a lack of standardization and day-to-day variability of microhematuria, which discouraged the inclusion of microhematuria in large multicenter studies. More recently, several studies from Asia, Europe and the USA have highlighted the importance of microhematuria assessment over longitudinal follow-up, using a systematic approach with either experienced personnel or automated techniques. We report lights and shadows of microhematuria evaluation in IgAN, looking for evidence for a more consistent consensus on its value as a marker of clinical and histological activity, risk assessment and prediction of treatment response. We propose that hematuria should be included as part of the clinical decision-making process when considering when to use immunosuppressive therapy and as part of criteria for enrollment into clinical trials to test drugs targeting the inflammatory reaction elicited by immune pathway activation in IgAN.
Collapse
Affiliation(s)
- Ladan Zand
- Division of Nephrology and Hypertension. Mayo Clinic. Rochester, MN, USA
| | | | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| |
Collapse
|
3
|
Kawamura T, Hirano K, Koike K, Nishikawa M, Shimizu A, Joh K, Katafuchi R, Hashiguchi A, Matsuzaki K, Maruyama S, Tsuboi N, Narita I, Yano Y, Yokoo T, Suzuki Y. Associations of corticosteroid therapy and tonsillectomy with kidney survival in a multicenter prospective study for IgA nephropathy. Sci Rep 2023; 13:18455. [PMID: 37891208 PMCID: PMC10611761 DOI: 10.1038/s41598-023-45514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Efficacy of systemic corticosteroid therapy (CS) for long-term kidney survival in patients with IgA nephropathy (IgAN) is controversial. Therefore, prospective studies evaluating targeted therapies to lymphatic tissues in mucosal immune system responsible for production of nephritogenic IgA have been desired worldwide. Here, we aimed to evaluate the associations of CS and combination therapy of CS and tonsillectomy (CS + Tx) with kidney survival, using database from a nationwide multicenter prospective cohort study on IgAN. Primary outcome was a 50% increase in serum creatinine from baseline or dialysis induction. The analysis included 941 patients (CS/CS + Tx/non-CS 239/364/338), 85 (9.0%) of whom reached outcomes during median follow-up of 5.5 (interquartile range 2.0-8.0) years. On overlap weighting analysis with balanced baseline characteristics, CS and CS + Tx were associated with lower risk of kidney events when compared with non-CS (hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.29-0.88 and HR 0.20, 95%CI 0.09-0.44, respectively). Notably, when compared with the CS, CS + Tx was associated with a lower risk of kidney events (HR 0.40, 95%CI 0.18-0.91). Present study demonstrated, keeping with favorable association of systemic CS with kidney survival, concurrent tonsillectomy as one of targeted interventions to lymphatic tissues may provide additional improvement to kidney survival in patients with IgAN.
Collapse
Affiliation(s)
- Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Keita Hirano
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Division of Nephrology, Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Masako Nishikawa
- Clinical Research Support Center, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ritsuko Katafuchi
- National Hospital Organization Fukuoka-Higashi Medical Center, Fukuoka, Japan
- Division of Nephrology, Department of Internal Medicine, Kano Hospital, Fukuoka, Japan
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Matsuzaki
- Department of Public Health, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuichiro Yano
- Department of Advanced Epidemiology, Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Ōtsu, Shiga, Japan
- The Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| |
Collapse
|
4
|
Tan J, Luo X, Yang J, Liu N, Jiang Z, Tang Y, Qin W. Clinicopathological characteristics and risk factors in elderly patients with biopsy-proven IgA nephropathy. Ren Fail 2022; 44:1026-1036. [PMID: 35766236 PMCID: PMC9246206 DOI: 10.1080/0886022x.2022.2087527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Immunoglobulin A nephropathy (IgAN) has been well studied among young people, but few data on clinicopathological characteristics, treatment response and outcomes for elderly IgAN patients are available. METHODS A cohort study of elderly IgAN patients was performed. The combined endpoints of renal outcome were a 50% decline in eGFR compared with the time of renal biopsy, end-stage kidney disease and/or death. Risk factors associated with poor renal outcomes were then determined. The benefits of immunosuppressant therapies were also evaluated by Kaplan-Meier survival curve analysis. RESULTS This study ultimately included 126 elderly patients with IgAN. Comparison between the endpoint and non-endpoint groups indicated that patients with poor outcomes had more severe clinical features, such as worse kidney function, severe hematuria and lower albumin levels. Cox regression analysis indicated that age (HR 1.15, 95% CI 1.02-1.29, p = 0.021), male gender (HR 9.71, 95% CI 1.00-97.56, p = 0.050), and urine red blood cells (HR 1.003, 95% CI 1.000-1.006, p = 0.029) were independent risk factors for poor renal outcome in elderly IgAN patients. To explore possible reasons accounting for the predictive value of age and sex, patients were divided into two groups based on these two variables. Patients in the geriatric group had lower serum albumin, estimated glomerular filtration rate, hemoglobin and aspartate aminotransferase levels than those in the quinquagenarian group. Male patients tended to have higher hemoglobin, higher alanine aminotransferase, and lower triglycerides and cholesterol levels than female patients. To investigate different treatment responses, patients were classified into two groups depending on treatment strategies (renin-angiotensin system inhibitors and immunosuppressive therapy), and the survival analysis indicated no significant difference in kidney outcome between the two groups (p > 0.05). This result still holds after adjusting for age, sex, eGFR, hematuria, and proteinuria. CONCLUSION Advanced age, male, and hematuria might be independently associated with poor kidney outcomes in elderly patients with IgAN. Immunosuppressive therapy might confer no overall benefit to older IgAN patients.
Collapse
Affiliation(s)
- Jiaxing Tan
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinyao Luo
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jiaqing Yang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Nuozhou Liu
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Jiang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yi Tang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
5
|
Toda M, Kume A, Hara M, Kimura H, Nakamura Y, Okumura K, Beppu H, Nakamura Y, Ogawa H, Kamei Y, Ishiwatari A, Kawanishi T, Ogawa T, Abe Y, Endo M, Wakai S. Efficacy and limitations of additional steroid pulse therapy in IgA nephropathy patients whose hematuria did not remit on tonsillectomy and protocol steroid pulse therapy. Clin Exp Nephrol 2022; 26:859-866. [PMID: 35486336 DOI: 10.1007/s10157-022-02226-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hematuria is the essential symptom of IgA nephropathy that has been suggested to be associated with long-term renal prognosis, Tonsillectomy and steroid pulse therapy (TSP), which is widely practiced in Japan, is effective for achieving hematuria remission. However, some cases are refractory to TSP, and additional steroid pulse therapy (SP) administered to these cases to achieve remission of hematuria. Nonetheless, the clinical significance of additional SP is unknown. METHODS In this retrospective study, we enrolled 99 patients from Okubo Hospital whose hematuria persisted following TSP. Patients were divided into the hematuria remission and non-remission groups. A multivariate regression analysis was performed on the factors that contributed to hematuria remission. RESULTS Following TSP, 103 of 403 patients (32.3%) did not achieve hematuria remission. Additional SP were performed in 99 of these patients, and remission of hematuria was achieved in 57 (57.6%). Patients with a greater degree of improvement in hematuria with TSP were significantly more likely to have remission of hematuria with additional SP (p = 0.0084*). Even in the hematuria non-remission group, both hematuria and proteinuria improved after additional SP. CONCLUSION In IgA nephropathy, additional SP could induce hematuria remission and reduce proteinuria.
Collapse
Affiliation(s)
- Minami Toda
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan.
| | - Aya Kume
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Masato Hara
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Hitomi Kimura
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Yuki Nakamura
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Koichiro Okumura
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Hiroko Beppu
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Yuka Nakamura
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Hina Ogawa
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Yuiko Kamei
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Ayumi Ishiwatari
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Tomoko Kawanishi
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Toshie Ogawa
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Yasutomo Abe
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Mariko Endo
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| | - Sachiko Wakai
- Division of Nephrology, Tokyo Metropolitan Health and Hospitals Corporation Ohkubo Hospital, 2-44-1 Kabuki-cho, Shinjyuku-ku, Tokyo, 160-8488, Japan
| |
Collapse
|
6
|
Ebbestad R, Sanaei Nurmi M, Lundberg S. Long-Term Outcomes of Patients with IgA Nephropathy Categorized by the International IgAN Risk Prediction Tool and by the Degree of Hematuria at Diagnosis. Nephron Clin Pract 2022; 146:573-583. [PMID: 35671707 PMCID: PMC9808712 DOI: 10.1159/000525001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/05/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Within 30 years, 20-50% of IgA nephropathy (IgAN) patients progress to end-stage kidney disease (ESKD). Identifying these patients can be difficult since renal function may deteriorate after being stable for years. The International IgAN Risk Prediction tool (IgAN-RPT) combines histologic lesions and clinical risk factors to predict renal outcome up to 5 or 7 years of follow-up. The clinical value beyond 7 years is unknown and microhematuria data has not been assessed. METHODS We studied the long-term renal outcome of 95 Swedish IgAN patients from the derivation cohort for the IgAN-RPT. The median follow-up was 11.2 years. Microhematuria at baseline was defined as high-degree by microscopy measurement of >10 red blood cell/high-power field of view or urine dipstick grading of 2-3. Primary outcome was defined as a 50% decrease in estimated glomerular filtration rate or ESKD. RESULTS The mean predicted 5-year risk for increasing quartiles was 0.95%, 2.57%, 5.88%, and 23.31% and the observed 5-year-outcome was 0%, 0%, 0%, and 33.33%. During continued follow-up, 0%, 4.2%, 21.7%, and 75.0% of patients reached the primary outcome. ROC curve analysis identified the 5-year risk thresholds of under 4% and over 11% for very low and very high-risk patients, respectively. High-degree microhematuria was not significantly associated with renal outcome (p = 0.14). CONCLUSIONS The IgAN-RPT identifies long-term high- and low-risk patients, which can guide decisions on the frequency of clinical control visits and the selection of patients for clinical trials. Patients with intermediate risk remain a clinical challenge with an urgent need for novel biomarkers and treatments. Microhematuria could be a valuable marker of inflammatory activity, but measurement needs to be standardized for implementation in risk prediction tools.
Collapse
Affiliation(s)
- Robin Ebbestad
- Department of Nephrology, Danderyd University Hospital, Stockholm, Sweden, .,Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden,
| | - Mazdak Sanaei Nurmi
- Department of Nephrology, Danderyd University Hospital, Stockholm, Sweden.,Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Sigrid Lundberg
- Department of Nephrology, Danderyd University Hospital, Stockholm, Sweden.,Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| |
Collapse
|
7
|
Bobart SA, Alexander MP, Shawwa K, Vaughan LE, Ghamrawi R, Sethi S, Cornell L, Glassock RJ, Fervenza FC, Zand L. The association of microhematuria with mesangial hypercellularity, endocapillary hypercellularity, crescent score and renal outcomes in immunoglobulin A nephropathy. Nephrol Dial Transplant 2021; 36:840-847. [PMID: 31859353 DOI: 10.1093/ndt/gfz267] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Microhematuria is common in immunoglobulin A nephropathy (IgAN). However, current prognostication is based on proteinuria and mesangial hypercellularity, endocapillary hypercellularity, segmental sclerosis, tubulointerstitial fibrosis and crescent (MEST-C) scores. METHODS In this retrospective study, we evaluated whether MEST-C score components are associated with the presence of microhematuria at biopsy and whether the degree of microhematuria during follow-up is associated with change in estimated glomerular filtration rate (eGFR), after adjusting for clinical and histological parameters. We identified 125 patients with biopsy-proven IgAN and MEST-C scoring who were not on immunosuppressive therapy at biopsy. Microhematuria was defined as ≥3 red blood cells (RBCs)/high-power field (hpf). RESULTS Of the 125 patients, 97 had microhematuria at baseline and were more likely to have M1, E1 and C ≥ 1 lesions (P < 0.05 for all) compared with patients without microhematuria. Of the 125 patients, 72 had follow-up data available. An increase in the degree of microhematuria was significantly associated with an eGFR decline of -0.81 mL/min/1.73 m2 [95% confidence interval (CI) -1.44 to -0.19, P = 0.01], after adjusting for follow-up time, proteinuria and T score. Severe microhematuria (≥21 RBCs/hpf) was associated with an even larger decline in eGFR (-3.99 mL/min/1.73 m2; 95% CI -6.9411 to -1.0552, P = 0.008), after similar adjustments. CONCLUSION Degree of microhematuria during follow-up is an independent predictor of eGFR decline after adjusting for clinical and histological parameters. Therefore, monitoring the degree of microhematuria as well as proteinuria is important when evaluating patients with IgAN. Additional studies using improvement in microhematuria as a primary surrogate outcome are needed.
Collapse
Affiliation(s)
- Shane A Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Khaled Shawwa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Lisa E Vaughan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Ranine Ghamrawi
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Lynn Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Richard J Glassock
- Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
8
|
Utility of remission criteria for the renal prognosis of IgA nephropathy. Clin Exp Nephrol 2021; 25:988-995. [PMID: 33974158 PMCID: PMC8357773 DOI: 10.1007/s10157-021-02069-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/22/2021] [Indexed: 11/10/2022]
Abstract
Background Novel criteria for the remission of Immunoglobulin A nephropathy (IgAN) based on an opinion survey of Japanese nephrologists and literature review were proposed in 2013. This single-center, longitudinal retrospective cohort study was conducted to validate this criteria. Methods Present study included the IgAN patients diagnosed between 2001 and 2005 in the Juntendo University Hospital. Remission of hematuria was defined as three consecutive dipstick test results of ( −) to ( ±) or a red blood cell count < 5 in urinary sediment per high-power field during at least 6 months. Remission of proteinuria was defined as three consecutive dipstick results of ( −) to ( ±) during at least 6 months. We categorized four groups according to the remission status which was assessed 2 years after the renal biopsy. The primary outcome was a 50% increase in the serum creatinine over the baseline. We evaluated the slope of eGFR decline (mL/min/1.73 m2/year) and a decrease in the eGFR of 30% from baseline eGFR as the secondary outcome, respectively. Results A total of 74 patients (male: 47.3%, median age: 30 years) were included and were followed for a median of 86.5 months. During the period, forty-one patients achieved neither remission of proteinuria nor hematuria (NR). Twelve patients met the primary study outcome. A survival analysis revealed that the NR had the worst prognosis and the steepest slope of eGFR decline. Conclusion Although further validation in a large cohort is necessary, these novel remission criteria for IgAN patients appear to predict the renal prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s10157-021-02069-w.
Collapse
|
9
|
He P, Wang H, Huang C, He L. Hematuria was a high risk for renal progression and ESRD in immunoglobulin a nephropathy: a systematic review and meta-analysis. Ren Fail 2021; 43:488-499. [PMID: 33685345 PMCID: PMC7946061 DOI: 10.1080/0886022x.2021.1879852] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: The relationship between hematuria, a typical presentation of immunoglobulin A nephropathy (IgAN), and long-term adverse prognosis of these patients is still controversial. This meta-analysis aims to clarify the effect of hematuria on renal outcomes in IgAN. Methods: Observational cohort studies reporting associations between various forms of hematuria and renal outcomes among IgAN patients were identified from the PubMed and Embase databases. The pooled adjusted risk ratios (RRs) were computed with random effects models. Results: Thirteen studies encompassing 5660 patients with IgAN were included. Patients with initial hematuria did not have a significantly increased risk of developing end-stage renal disease (ESRD) compared with those without hematuria (RR, 1.32; 95% CI, 0.87–2.00; p = .19). However, initial microscopic hematuria was associated with an 87% increase in the risk of ESRD (RR, 1.87; 95% CI, 1.40–2.50; p < .001), while macroscopic hematuria was associated with a 32% decrease in the risk of ESRD (RR, 0.68; 95% CI, 0.58–0.79; p < .001). Additionally, persistent hematuria might be an independent risk factor for ESRD or a 50% decline in eGFR. Conclusions: Among IgAN patients, hematuria, including initial microscopic hematuria and even persistent hematuria, was possibly associated with renal progression and ESRD. However, independent of other classical predictors, initial macroscopic hematuria might be a protective factor for IgAN.
Collapse
Affiliation(s)
- Peng He
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Hanmin Wang
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Chen Huang
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Lijie He
- Department of Nephrology, State Key Laboratory of Cancer Biology & Institute of Digestive Diseases, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| |
Collapse
|
10
|
Yu GZ, Guo L, Dong JF, Shi SF, Liu LJ, Wang JW, Sui GL, Zhou XJ, Xing Y, Li HX, Lv JC, Zhang H. Persistent Hematuria and Kidney Disease Progression in IgA Nephropathy: A Cohort Study. Am J Kidney Dis 2020; 76:90-99. [DOI: 10.1053/j.ajkd.2019.11.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 11/21/2019] [Indexed: 11/11/2022]
|
11
|
Mastrangelo A, Serafinelli J, Giani M, Montini G. Clinical and Pathophysiological Insights Into Immunological Mediated Glomerular Diseases in Childhood. Front Pediatr 2020; 8:205. [PMID: 32478016 PMCID: PMC7235338 DOI: 10.3389/fped.2020.00205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
The kidney is often the target of immune system dysregulation in the context of primary or systemic disease. In particular, the glomerulus represents the anatomical entity most frequently involved, generally as the expression of inflammatory cell invasion or circulant or in situ immune-complex deposition. Glomerulonephritis is the most common clinical and pathological manifestation of this involvement. There are no universally accepted classifications for glomerulonephritis. However, recent advances in our understanding of the pathophysiological mechanisms suggest the assessment of immunological features, biomarkers, and genetic analysis. At the same time, more accurate and targeted therapies have been developed. Data on pediatric glomerulonephritis are scarce and often derived from adult studies. In this review, we update the current understanding of the etiologic events and genetic factors involved in the pathogenesis of pediatric immunologically mediated primitive forms of glomerulonephritis, together with the clinical spectrum and prognosis. Possible new therapeutic targets are also briefly discussed.
Collapse
Affiliation(s)
- Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Jessica Serafinelli
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marisa Giani
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| |
Collapse
|
12
|
Moriyama T. Clinical and histological features and therapeutic strategies for IgA nephropathy. Clin Exp Nephrol 2019; 23:1089-1099. [PMID: 30968243 DOI: 10.1007/s10157-019-01735-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/24/2019] [Indexed: 01/21/2023]
Abstract
Chronic glomerulonephritis is the second most common reason, after diabetic nephropathy, for initiation of dialysis in Japan and IgA nephropathy (IgAN) is the most prevalent form of chronic glomerulonephritis. In the half century since IgAN was initially reported, our understanding of the long-term prognosis, clinical and histological features, pathogenesis of onset and progression, risk factors for progression, and appropriate treatment under different clinical and histological conditions, has steadily increased. Strong experimental and clinical evidence, the Clinical Practice Guidelines for IgA Nephropathy in Japan, the Oxford Classification, and the Kidney Disease Improving Global Outcomes guidelines have all contributed to the appropriate treatment of IgAN. Several intensive therapies, such as tonsillectomy, steroid therapy, and their combinations, can result in clinical remission, and prevent the progression to end stage renal disease (ESRD). However, some IgAN patients still progress to ESRD even when treated with intensive therapies. In this review, we discuss the clinical and histological features of IgAN, focusing primarily on our previous reports, and our opinions on therapeutic strategies for IgAN.
Collapse
Affiliation(s)
- Takahito Moriyama
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| |
Collapse
|
13
|
Coppo R, Fervenza FC. Persistent Microscopic Hematuria as a Risk Factor for Progression of IgA Nephropathy: New Floodlight on a Nearly Forgotten Biomarker. J Am Soc Nephrol 2017; 28:2831-2834. [PMID: 28739649 DOI: 10.1681/asn.2017060639] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy; and
| | | |
Collapse
|
14
|
Sevillano AM, Gutiérrez E, Yuste C, Cavero T, Mérida E, Rodríguez P, García A, Morales E, Fernández C, Martínez MA, Moreno JA, Praga M. Remission of Hematuria Improves Renal Survival in IgA Nephropathy. J Am Soc Nephrol 2017; 28:3089-3099. [PMID: 28592423 DOI: 10.1681/asn.2017010108] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/29/2017] [Indexed: 11/03/2022] Open
Abstract
Hematuria is a cardinal symptom in IgA nephropathy, but its influence on the risk of disease progression has been scarcely investigated. We followed a cohort of 112 patients with IgA nephropathy for a mean±SEM period of 14±10.2 years, during which clinical and analytic risk factors (including urine sediment examination) were regularly recorded. According to the magnitude of time-averaged hematuria, we classified patients as those with persistent hematuria and those with negative or minimal hematuria. We also classified patients according to the magnitude of time-averaged proteinuria (>0.75 or ≤0.75 g/d). The proportion of patients reaching ESRD or a 50% reduction of renal function was significantly greater among patients with persistent hematuria than patients with minimal or negative hematuria (30.4% and 37.0% versus 10.6% and 15.2%, respectively; P=0.01). Multivariable analysis revealed time-averaged hematuria, time-averaged proteinuria, renal function at baseline, and the presence of tubulointerstitial fibrosis on renal biopsy as independent predictors of ESRD. After hematuria disappearance, which occurred in 46% of the patients, the rate of renal function decline changed from -6.45±14.66 to -0.18±2.56 ml/min per 1.73 m2 per year (P=0.001). Patients with time-averaged proteinuria >0.75 g/d had significantly poorer renal survival than those with time-averaged proteinuria ≤0.75 g/d. However, on further classification by time-averaged hematuria, only those patients with time-averaged proteinuria >0.75 g/d and persistent hematuria had significantly worse renal survival than those in the other three groups. In conclusion, remission of hematuria may have a significant favorable effect on IgA nephropathy outcomes.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Cristina Fernández
- Research and Clinical Epidemiology Unit, Department of Preventive Medicine, Hospital Clinic, San Carlos, Madrid, Spain
| | | | - Juan Antonio Moreno
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; and
| | - Manuel Praga
- Departments of Nephrology and .,Department of Medicine, Complutense University, Madrid, Spain
| |
Collapse
|
15
|
Clinical and histological risk factors for progression of IgA nephropathy: an update in children, young and adult patients. J Nephrol 2016; 30:339-346. [PMID: 27815919 DOI: 10.1007/s40620-016-0360-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 10/21/2016] [Indexed: 01/13/2023]
Abstract
The identification of risk factors conditioning the progression of immunoglobulin (Ig)A nephropathy (IgAN) is needed due to the variability of the outcome of this renal disease, which ranges from remission or indolent course to progressive slow loss of renal function or rapidly evolving chronic renal failure. Based on the supposed individual risk of progression, the therapy is modulated from renin-angiotensin inhibitors to corticosteroids, alone or associated with other powerful but potentially harmful immunosuppressors. Over the last 20 years, several studies have produced great advances in the field of biomarkers for detecting risk factors that play a role in the progression of IgAN. This review will focus on the clinical and histological risk factors which have been detected and validated by the majority of the studies and which may presently be considered of value for prognostication of outcome in patients with IgAN, driving the individual treatment choice.
Collapse
|
16
|
Glassock RJ. Moderator's view: Treatment of IgA nephropathy—getting comfortable with uncertainty. Nephrol Dial Transplant 2016; 31:1776-1780. [DOI: 10.1093/ndt/gfw284] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/17/2016] [Indexed: 02/02/2023] Open
|