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Stangou MJ, Marinaki S, Papachristou E, Liapis G, Pateinakis P, Gakiopoulou H, Nikolaidou C, Kolovou K, Lampropoulou IT, Zerbala S, Papadea P, Dounousi E, Balafa O, Pavlakou P, Andrikos A, Balassi E, Manolakaki P, Moustakas G, Galitsiou D, Mitsopoulos E, Vourlakou C, Choulitoudi V, Andronikidi PE, Stefanidis I, Golfinopoulos S, Dafnis E, Stylianou K, Panagoutsos S, Papadogianakis A, Tzanakis I, Sioulis A, Vlahakos D, Grapsa I, Tsilivigkou M, Kaperonis N, Paliouras C, Dioudis C, Spaia S, Apostolou T, Iatrou C, Boletis J, Goumenos D, Papagianni A. Histological grading in primary membranous nephropathy is essential for clinical management and predicts outcome of patients. Histopathology 2019; 75:660-671. [PMID: 31318463 PMCID: PMC6856983 DOI: 10.1111/his.13955] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 01/06/2023]
Abstract
Aims Diagnosis of primary membranous nephropathy (PMN) is mainly based on immunofluorescence/immunohistochemistry findings. However, assessment of specific features on optical microscopy can help to estimate the severity of the disease, guide treatment and predict the response. The aim of this study was to identify, classify and grade the precise histological findings in PMN to predict renal function outcome and guide treatment. Methods and results Histological parameters, including focal segmental sclerosis (FSGS), tubular atrophy (TA), interstitial fibrosis (IF) and vascular hyalinosis (VH), were re‐evaluated in 752 patients with PMN. Their predictive value was estimated separately, and also in a combination score (FSTIV) graded from 0 to 4. Finally, the impact of histology was assessed in the response to immunosuppressive treatment. Mean age of patients was 53.3 (15–85) years and most presented with nephrotic syndrome. FSGS was present in 32% and VH in 51% of the patients, while TA and IF were graded as stage ≥1 in 52% and 51.4%, respectively. The follow‐up period was 122.3 (112–376) months. FSGS, TA and IF and VH were associated with impaired renal function at diagnosis (P = 0.02, P < 0.0001, P = 0.001 and P = 0.02, respectively) and at the end of follow‐up (P = 0.004, P < 0.0001, P < 0.0001 and P = 0.04, respectively). In multiple regression and binary logistic analysis, the presence of FSGS and degree of TA were the most significant parameters predicting renal function outcome, defined either by eGFR (end), FSGS (r = 0.6, P < 0.0001) and TA (r = 0.6, P < 0.0001), or by the endpoint of >50% eGFR reduction, FSGS (P = 0.001) and TA (P = 0.02). Also, patients presented with FSGS, IF, VH and/or with FSTIV > 1 could benefit from immunosuppression, regardless of clinical presentation. Conclusions The presence and degree of four histological indices, FSGS, VH, TA and IF, assessed separately or in combination, and FSTIV score not only predict renal function outcome after long‐term follow‐up, but can also help in the choice of appropriate treatment. Decisions concerning immunosuppressive treatment can be guided by pathology regardless of clinical findings.
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Affiliation(s)
- Maria J Stangou
- Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Smaragdi Marinaki
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | - George Liapis
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | - Hara Gakiopoulou
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | - Kyriaki Kolovou
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | | | | | | | - Olga Balafa
- University Hospital of Ioannina, Ioannina, Greece
| | | | | | | | | | | | | | | | | | | | | | | | | | - Eugene Dafnis
- University Hospital of Heraklion, Heraklion, Crete, Greece
| | | | | | | | | | | | - Demetrios Vlahakos
- Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | - Irene Grapsa
- Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | - Sophia Spaia
- General Hospital of Thessaloniki 'Agios Pavlos', Thessaloniki, Greece
| | | | | | - John Boletis
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
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Stangou M, Marinaki S, Papachristou E, Kolovou K, Sambani E, Zerbala S, Papadea P, Balafa O, Rapsomanikis KP, Andrikos A, Manolakaki P, Papadopoulou D, Mitsopoulos E, Liakou H, Andronikidi PE, Choulitoudi V, Moustakas G, Galitsiou D, Dafnis E, Stylianou K, Stefanidis I, Golfinopoulos S, Panagoutsos S, Tsilivigkou M, Papadogianakis A, Tzanakis I, Sioulis A, Vlachakos D, Grapsa E, Spaia S, Kaperonis N, Paliouras C, Dioudis C, Papoulidou F, Apostolou T, Iatrou C, Boletis I, Goumenos D, Papagianni A. Immunosuppressive regimens based on Cyclophospamide or Calcineurin inhibitors: Comparison of their effect in the long term outcome of Primary Membranous Nephropathy. PLoS One 2019; 14:e0217116. [PMID: 31404062 PMCID: PMC6690570 DOI: 10.1371/journal.pone.0217116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Management of the Primary Membranous Nephropathy (PMN) usually involves administration of immunosuppressives. Cyclophosphamide (Cyclo) and Calcineurin Inhibitors (CNIs) are both widely used but only limited data exist to compare their efficacy in long term follow-up. AIM The aim of the present study was to estimate and compare long term effects of Cyclo and CNIs in patients with PMN. PATIENTS-METHODS Clinical data, histologic findings and long term outcome were retrospectively studied. The response to treatment and rate of relapse was compared between patients treated with CNIs or Cyclo based immunosuppressive regimens. RESULTS Twenty three centers participated in the study, with 752 PMN patients (Mean age 53.4(14-87) yrs, M/F 467/285), followed for 10.1±5.7 years. All patients were initially treated with Renin Angiotensin Aldosterone System inhibitors (RAASi) for at least 6 months. Based on their response and tolerance to initial treatment, patients were divided into 3 groups, group I with spontaneous remission, who had no further treatment, group II, continued on RAASi only, and group III on RAASi+immunosuppression. Immunosuppressive regimes were mainly based on CNIs or Cyclo. Frequent relapses and failure to treatment were more common between patients who had started on CNIs (n = 381) compared to those initially treated with Cyclo (n = 110), relapse rate: 25.2% vs. 6.4%, p<0.0001, and no response rate: 22.5% vs. 13.6%, p = 0.04, respectively. CONCLUSIONS Long term follow up showed that administration of Cyclo in PMN is followed by better preservation of renal function, increased response rate and less frequent relapses, compared to CNIs.
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Affiliation(s)
- Maria Stangou
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Kyriaki Kolovou
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Erasmia Sambani
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Synodi Zerbala
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - Panagiota Papadea
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Aimilios Andrikos
- Department of Nephrology, Hatzikosta General Hospital of Ioannina, Ioannina, Greece
| | - Panagiota Manolakaki
- Department of Nephrology, Hatzikosta General Hospital of Ioannina, Ioannina, Greece
| | - Dorothea Papadopoulou
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Mitsopoulos
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Helen Liakou
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | | | | | - George Moustakas
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | - Dimitra Galitsiou
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | - Eugene Dafnis
- Department of Nephrology, University Hospital of Heraklion, Heraklion Crete, Greece
| | - Kostas Stylianou
- Department of Nephrology, University Hospital of Heraklion, Heraklion Crete, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, Larissa, Greece
| | | | - Stylianos Panagoutsos
- Department of Nephrology, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Maria Tsilivigkou
- Department of Nephrology, Tzaneion General Hospital of Piraeus, Athens, Greece
| | | | - Ioannis Tzanakis
- Department of Nephrology, General Hospital of Chania, Chania Crete, Greece
| | - Athanasios Sioulis
- Section of Nephrology, 1st Department of Medicine, AHEPA University General Hospital, Thessaloniki, Greece
| | - Dimitrios Vlachakos
- Department of Nephrology, Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | - Eirini Grapsa
- Department of Nephrology, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Spaia
- Department of Nephrology, General Hospital of Thessaloniki "Agios Pavlos", Thessaloniki, Greece
| | - Nikolaos Kaperonis
- Department of Nephrology, Hellenic Red Cross Hospital Korgialeneio-Benakeio, Athens, Greece
| | | | | | - Fani Papoulidou
- Department of Nephrology, General Hospital of Kavala, Kavala, Greece
| | | | - Christos Iatrou
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - Ioannis Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Aikaperini Papagianni
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
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