The Added Value of Crescents on Oxford Classification Score in Risk Stratification of End-stage Kidney Disease in Patients with IgA Nephropathy

INTRODUCTION

Crescents (C) have been recently added to the Oxford classification of IgA nephropathy (IgAN) consisting of mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental sclerosis (S) and tubular atrophy/ interstitial fibrosis (T) (MEST). The aim of the study was to assess the added impact of crescents, on development of end-stage kidney disease (ESKD) in IgAN patients Methods. On-hundred fifteen IgAN patients (76% male, mean age: 37 ± 13 years, mean serum creatinine: 4.0 ± 4.3 mg/dL, mean proteinuria: 3.4 ± 2.5 g/d) were followed for 43 ± 29 months. MEST score was defined according to Oxford classification (M0/M1, E0/ E1, S0/S1). To increase the power, T was defined as T0 ≤ 25% and T1 > 25%. Crescents were defined as C0, "absence" and C1 "at least one" crescent. In sensitivity analysis, the risk of ESKD was estimated at different cut-off levels of at least 10, 20, and 30% crescents.

RESULTS

Forty patients (35%) developed ESKD. Among those 14% with at least one crescent, 21 patients (46%) developed ESKD. In 11 patients with C ≥ 30%, 66% and among 57 patients with T1, 60% and in 27 patients with T1 + C1 74% developed ESKD. In adjusted model, only C ≥ 30% (HR = 3.15, 95% CI: 1.15 to 11.00; P = 0.027) and the presence of T1+ C1 (HR = 7.18, 95% CI: 1.90 to 27.10, P = 0.004) were associated with increased risk of ESKD. The median kidney survival was 78.0 months (95% CI: 70.5 to 85.6 months), in patients with T0 + C0 and 32.3 months (95% CI: 19.3 to 45.3 months) in patients with T1 + C1.

CONCLUSION

In this study T ≥ 25%, and the presence of crescents ≥ 30%, were independently associated with increased risk of ESKD. This risk was strongly increased in the combined presence of at least one crescent and T1 ≥ 25%, that predicted a high ESKD rate.  DOI: 10.52547/ijkd.6685.

Kidney Outcome in Primary Focal Segmental Glomerulosclerosis (FSGS) by Using a Predictive Model

INTRODUCTION

Focal segmental glomerulosclerosis (FSGS) is one of the important causes of end stage kidney disease (ESKD). We evaluated the progression risk factors of primary FSGS to chronic kidney disease (CKD) or ESKD with a predictive model including clinical and histological predictors.

METHODS

201 patients with primary FSGS (59% male, mean age: 38 ± 15 years), were studied. Time-dependent Cox model and C statistics were used for the predictive model. Interaction and correlation between independent variables were estimated.

RESULTS

During 55 ± 27 months of follow-up, 82 patients (41%) developed CKD (46) or ESKD (36) patients. In adjusted model, 1 unit of higher serum creatinine (SCr) at baseline (HR = 1.39, 95% CI: 1.15 to 1.70) and 1% increase in glomeruli with segmental glomerulosclerosis (SGS) (HR = 1.03, 95% CI: 1.02 to 1.04) or interstitial fibrosis/tubular atrophy (IF/TA) (HR = 1.03, 95% CI: 1.01 to 1.05) increased the risk of CKD/ESKD. In adjusted model, higher baseline proteinuria and collapsing variant were not associated with risk of CKD/ESKD. By adding SGS and IF/TA scores to baseline SCr in the model, discrimination by C statistics was 0.83 (95% CI: 0.77 to 0.90). Median renal survival was 3.1 years (95% CI: 2.2 to 4.1 years) in patients with highest risk score (baseline eGFR < 25 mL/min/1.73m2 + IF/TA/SGS > 50%), and 8.1 years (95% CI: 7.7 to 8.6 years).in those with lowest score (baseline eGFR > 75 mL/ min/1.73m2 + IF/TA/SGS < 5%).

CONCLUSION

In primary FSGS, higher baseline SCr, increased SGS and IF/TA, but not baseline proteinuria and collapsing pathology, were the predictors for CKD/ESKD. These findings indicated the importance of timely detection and referral in prognosis of primary FSGS. DOI: 10.52547/ijkd.6442.

P0111AN UPDATE ON EPIDEMIOLOGY AND CLINICOPATHOLOGIC CORRELATION OF RENAL BIOPSY FINDINGS - A TERTIARY KIDNEY CENTRE REPORT

Background and Aims

Several studies have reported the results of renal biopsies from different registries and single centres. In most series focal and segmental glomerulosclerosis (FSGS), IgA nephropathy (IgAN), membranous glomerulopathy (MG) and lupus nephritis (LN) have been reported as the most common primary and secondary glomerulonephritis (GN). This study was conducted to update the reports of our hospital, as the main referral kidney centre of the country.

Method

Data from 4713 patients, who had undergone renal biopsy between Sept-1999 to Sept.-2019 were extracted from the GN data registry of our centre. Demographic data, renal syndrome at presentation and laboratory findings were studied. Almost all kidney specimens had been studied with light and immunofluoroscent microscopes and in selected cases with electron microscope. Nephrotic syndrome (NS) was defined as proteinuria &gt;3.5 g/day or &gt;3 g/day, if associated with hyperlipidemia, hypoalbuminemia and edema. Nephritic syndrome was defined as proteinuria &gt;500 mg/day and hematuria, with or without hypertension and/or serum Cr (SCr) ≥1.4 mg/dl. Subnephrotic (SN) proteinuria was defined as proteinuria of 200 -3000 mg/day. Acute kidney injury (AKI) was defined as increase in SCr &gt;1.4 during the past few days to weeks before admission.

Results

The most frequent type of renal pathology was MG (25.2%) followed by FSGS (13.6%), IgAN (12%), LN (8.9%), minimal change disease (MCD) (7%), crescentic GN (6.2%) and paraprotein associated GN (4.3%). The prevalence of different renal pathologies changed significantly over time (p-value:0.000) (figure).The most common clinical presentation was NS (60.2%), followed by SN proteinuria (15.2%), nephritic syndrome (12%) and AKI (7.5%). Age, sex, clinical syndrome at presentation and hypertension were significantly different between major pathological diagnostic groups (p=0.000). Table shows the detailed clinical features of the most important glomerulonephritides in our centre. Figure shows the changes in prevalence of each pathologic diagnosis over 21 years.

Conclusion

In our series the most common types of GN were MG, FSGS and IgAN, which are the most frequent glomerulonephritides in other biopsy series with various orders. Most of our patients presented with NS, followed by SN proteinuria. The relative frequency of MPGN and LN have reduced and FSGS has increased over time.

Impact of oxygen therapy to ameliorate contrast-induced nephropathy in patients with acute coronary syndrome undergoing emergency angiography; a double-blinded clinical trial

Introduction: Contrast-induced nephropathy (CIN) is one of the major causes of acute kidney injury. Objectives: Regarding an increase in mortality and morbidity in patients with CIN, this study aimed to evaluate the effect of oxygen therapy in prevention of the CIN in individuals with acute coronary syndrome undergoing emergent angiography. Patients and Methods: This study was a double-blinded clinical trial with control group (parallel design), randomized, and with a sample size of 204 individuals conducted on male or female patients over 35 years old and suspected of coronary artery disease undergoing emergent angiography refereed to Rasoul Akram hospital in 2018. Participants were divided into 2 groups (supplementary oxygen and oxygen-free groups). The first group received two to three liters of oxygen per minute from 10 minutes before the start of the procedure until the end of the procedure, and the second group inhaled the oxygen in the room air. Arterial blood gas (ABG) was taken prior to receiving oxygen and at the end of the procedure. Serum creatinine level was tested for all individuals before and 48 hours after the procedure. Results: The mean age in intervention and control groups was 61.66 ± 14.64 years and 60.49 ± 11.59 years, respectively (P=0.54). Mean glomerular filtration rate (GFR) and serum creatinine before and after angiography was not significantly different (P>0.05). There was a significant difference between the two genders regarding the development of CIN (P=0.002), which was higher in women from that of men. Female gender was a strong risk factor and approximately increased four times the risk of CIN (OR = 4.1; (P=0.001). History of chronic kidney disease (CKD) and hypertension (HTN) also produced such a situation (OR = 22.37; P=0.007). Conclusion: According to the results, oxygen therapy has no effect on the occurrence of CIN. It is also found that female gender, history of CKD and hypertension are risk factors for CIN.