Is there long-term value of pathology scoring in immunoglobulin A nephropathy? A validation study of the Oxford Classification for IgA Nephropathy (VALIGA) update

Background

It is unknown whether renal pathology lesions in immunoglobulin A nephropathy (IgAN) correlate with renal outcomes over decades of follow-up.

Methods

In 1130 patients of the original Validation Study of the Oxford Classification for IgA Nephropathy (VALIGA) cohort, we studied the relationship between the MEST score (mesangial hypercellularity, M; endocapillary hypercellularity, E; segmental glomerulosclerosis, S; tubular atrophy/interstitial fibrosis, T), crescents (C) and other histological lesions with both a combined renal endpoint [50% estimated glomerular filtration rate (eGFR) loss or kidney failure] and the rate of eGFR decline over a follow-up period extending to 35 years [median 7 years (interquartile range 4.1–10.8)].

Results

In this extended analysis, M1, S1 and T1–T2 lesions as well as the whole MEST score were independently related with the combined endpoint (P < 0.01), and there was no effect modification by age for these associations, suggesting that they may be valid in children and in adults as well. Only T lesions were associated with the rate of eGFR loss in the whole cohort, whereas C showed this association only in patients not treated with immunosuppression. In separate prognostic analyses, the whole set of pathology lesions provided a gain in discrimination power over the clinical variables alone, which was similar at 5 years (+2.0%) and for the whole follow-up (+1.8%). A similar benefit was observed for risk reclassification analyses (+2.7% and +2.4%).

Conclusion

Long-term follow-up analyses of the VALIGA cohort showed that the independent relationship between kidney biopsy findings and the risk of progression towards kidney failure in IgAN remains unchanged across all age groups and decades after the renal biopsy.

[HFR vs HDF-ON line: plasmatic amino acids loss evaluation]

PURPOSE

The high convection dialytic techniques, such as hemodiafiltration (HDF), can cause the loss of important molecules such as growth factors, vitamins and amino acids. Hemodiafiltration reinfusion (HFR) is an HDF on-line process, using a sipping cartridge, able to remove uremic toxins and give back a "repaired" ultra-filtrate to the patient. We aimed to establish the plasmatic amino acid levels before and after dialysis in HFR vs. HDF on-line, with scrupulous attention to branched chain amino acids (BCAA) such as isoleucine, leucine and valine. These amino acids, often present with low plasmatic levels in hemodialyzed patients, seem to be related to a picture of malnourishment.

METHODS

Eleven male patients on bicarbonate dialysis, for at least 1 yr, were evaluated (average dialytic age = 88 months, /average age = 67 yrs), with good dialytic efficiency and body mass levels, randomized in HFR or HDF on-line (filter PAN AN 69) for 1 week of treatment, respectively. The different results of each method were controlled for the same patient. Blood samples were taken before and after dialysis in each 2nd hemodialytic weekly session. Total amino acids, essential, non-essential and BCAA were determined by gas-chromatography.

RESULTS

There was no difference detected in pre-dialytic plasmatic levels of analyzed amino acids between the two groups. In post-dialysis, HDF patients demonstrated a total essential, non-essential amino acid and BCAA higher loss rate, compared to HFR patients. Post-dialysis amino acid level averages were: total amino acids in HDF 1852 +/- 302.6 micromol/L, in HFR 2395 +/- 492.8 micromol/L (p = 0.018); essential amino acids in HDF 428.8 +/- 118.2 micromol/L, in HFR 510.3 +/- 129.3 micromol/L (p = 0.022); non-essential amino acids in HDF 1176 +/- 213 micromol/L, in HFR 1546 +/- 339.2 micromol/L (p = 0.01); BCAA in HDF 242.7 +/- 83.42 micromol/L, and in HFR 286.7 +/- 89.9 micromol/L (p = 0.03).

CONCLUSIONS

Since low plasmatic BCAA levels are related to anorexia and malnourishment, the loss of these amino acids can be important in the dialytic technique choice. HFR can offer an outstanding advantage, combining a high convection treatment with medium molecule removal, without compromising physiologic molecule loss.

[Safety in dialysis rooms. Biologic risks]

The search for quality in the health service cannot lead aside the safety of its operators and users, subject to the well defined parameters of Law 626. This study makes a preliminary examination of the accidents occurring in our Health District which comprises three hospitals, 600 beds and 1,800 employees. A total of 172 accidents have been reported. The percentages can be broken down between the various sectors: 73% of accidents involve nurses, 9% involve doctors and 1% administrative personnel. The greatest risk in hemodialysis is the biological factor (through accidental cuts or pricks which account for 67% of the accidents reported) and involves humans (both patients and personnel), monitors and environments as the sources of pathogens. The most frequently isolated germs are E. coli and Pseudomonas. It has been shown that prevention is above all based on the accuracy with which procedures are followed. The risk of hepatitis C has not yet been resolved, as is affinned in a review reported in the study. The HIV risk gives the greatest cause for concern, even if only 0.2% after exposure compared to 15-36 for HbsAg. Compliance with universal rules for prevention and post-exposure procedures provides an adequate guarantee for prevention.

[Heart failure resistant to drug therapy. Nephrologic approach]

BACKGROUND

The congestive heart failure (IV cl. NYHA) refractory to medical therapy, can be treated with ultrafiltrative method such as extracorporeal ultrafiltration (UF), intermittent veno-venosus hemofiltration, intermittent peritoneal dialysis (IPD) or chronic ambulatory peritoneal dialysis (CAPD).

METHODS

Sixty-one patients suffering from SCC have been managed by combining medical therapy with ultrafiltrative treatment.

RESULTS

28% (17 patients) died within a week from ultrafiltrative therapy beginning. 39% (24 patients) took up to respond to medical therapy (responders). 33% (20 patients) didn't give a proper response to pharmacological therapy (non responders), therefore a ultrafiltration program with chronic ambulatory peritoneal dialysis (CAPD) has been undertaken. Among ultrafiltrative methods applied to patients, IVVH is the most effective. Clinical parameters analysis, relevant to dehydration acute phase, points out: an evident loss of corporeal weight between dehydration pre-post phases in all 3 groups, with statistically significant results; a SAP values reduction between the beginning and the end of treatment in all 3 groups; a PAD values reduction in the group of deceased and non responders. This value remains stable in responders group. Non responders patients, inserted in a ultrafiltration program with CAPD present the following survival rate: 55%: 6 months; 35%: 1 years; 15%: 4 years. These patients maintain a good self-management in 50%, sufficient in 35% and totally partner-dependent in 15%.

CONCLUSIONS

Ultrafiltration method together with pharmacological therapy allows a resetting of neuro-endocrine and electrolytic system in refractory congestive heart failure patients and a recovery of a pharmacological response. Without such a response a cardio-circulatory balance can be maintained through a CAPD method.

[Critical review of renal transplantation data from the Piedmontese Regional Dialysis and Transplantation Registry]

On 31/12/1995 a total of 1,128 Piedmontese uremic patients had undergone kidney transplantation, with 65% of operations performed by the Regional Reference Centre and 35% by extra-regional centres. Waiting time for dialysis was less than 5 years in over half of the patients most of whom were aged between 40 and 60 years old. In overall terms, the patient survival rate was 94%, 87%, 75% at 24, 60, 120 months respectively, with a statistically significant improvement when the curve was evaluated in the patient-pool treated with cyclosporine (84% versus 87% at 7 years). Organ survival was 76% at 21 years and 42% at 10 years, and results were again improved by the use of cyclosporine. Pathologies affecting the transplanted organ represent the main cause of morbidity; drop-out during dialysis is caused above all by immunological diseases. Infectious pathologies were responsible for the majority of deaths in this population.

[Medical nephropathies: what has changed in 20 years]

The authors analyse the series of patients with medical nephropathy undergoing renal biopsy between 1973 and 1993 in order to make a diagnostic and prognostic comparison between the first (ID) and second (IID) decade. Clinical indications for biopsy, which became more precise during the second decade, led to the diagnosis of fewer patients with normal histology; the introduction of ME and IF allowed non-significant histological conditions to be reduced during IID; echo-guided biopsy has led to a reduced number of post-biopsy complications in IID compared to ID. Epidemiological analysis reveals the reduction of focal glomerulosclerosis in IID in favour of glomerulonephritis with IgA deposits in correlation with the use of IF; the increase in mebranous glomerulonephritis secondary to increased antigenic stimuli; reduced acute post-infective glomerulonephritis and membrane-proliferative glomerulonephritis owing to an improved prophylaxis of sources of infection. Among the patients undergoing renal biopsy and commencing dialysis an increase was observed in IID in the number of cases of membranous glomerulonephritis or caused by IgA deposits. There was an increased interval between biopsy and the start of dialysis in IID compared to ID, in spite of fewer patients receiving immunosuppressive therapy. This was probably due to the increased number of pathologies with a slower evolution, thus justifying the postponement of the start of dialysis.

[Heart involvement in anorexia nervosa: an electrocardiographic, functional and morphological study]

Mental anorexia (MA) is the most frequent condition of malnutrition in industrialized countries. Sudden death in MA is not infrequent. Furthermore, the role of nutritional state as an important determinant of myocardial function is known. Cardiovascular function was studied in 9 patients with MA. Blood electrolytes and thyroid function were assessed, basal and dynamic ECG, chest roentgenogram, M-mode echocardiography, ergometric test, cardiac output measurement and, in two cases, magnetic nuclear resonance (MNR) were performed. Our data confirm the ECG changes which were preeminent in the clinical context, as predictors of possible major, life-threatening arrhythmic events. The correct QT interval was normal in all patients. In 4 cases with heart rate less than 40 b/min, Holter ECG showed ventricular and atrial extrasystolic beats. In one case S-A blocks with idioventricular substitutive beats were recorded; the normal performance under maximal strain stands for a normal functional reserve. Blood electrolytes were in the normal range. The hypothalamic-pituitary axis can be considered as a cocausal factor by means of autonomic nervous system modulations. Echocardiography revealed only a mild reduction of ventricular wall thickness. Scattered degenerative myocardial involvement as shown by MNR imaging, could be the anatomical counterpart of a clinically emerging cardiomyopathy with potentially severe arrhythmias.

[Lipoprotein (a)]

Lipoprotein(a) [Lp(a)] is a high molecular weight plasma protein structurally related to low density lipoprotein (LDL), but with distinct metabolic and biologic features. Six different isotypes may be found among the general population; they are inherited as a codominant autosomic monogenic trait. Lp(a) levels in the blood are strictly conditioned by the isotype and much less, if at all, by other environmental or metabolic factors. The Lp(a) catabolic rate is very similar among different individuals and comes from the balance of two complementary pathways: uptake from blood by tissue cells via LDL-receptors, and non-receptor macrophagic internalization at the level of the reticulo-endothelial system. Its high content in lysolecithins and cholesterol, and the close structural similarity of its peptidic component to plasminogen, make Lp(a) a crucial "meeting point" of two main physiopathologic elements of atherogenesis:lipoprotein metabolism and fibrinolysis. This particular role would seem to explain the experimental finding of a close relation between Lp(a) plasmatic levels and the severity of atheromatous processes. Deep understanding of Lp(a) physiopathology is therefore expected to be a powerful tool for the creation of a comprehensive and practical model of atherogenesis and to enable us to deal with prognostic, preventive and therapeutic problems in this field from a new view point.