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      Validation of the Oxford Classification of IgA Nephropathy: A Single-Center Study in Korean Adults

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          Abstract

          Background/Aims

          The recently published Oxford classification of IgA nephropathy (IgAN) proposed a split system for histological grading, based on prognostic pathological features. This new classification system must be validated in a variety of cohorts. We investigated whether these pathological features were applicable to an adult Korean population.

          Methods

          In total, 69 adult Korean patients with IgAN were analyzed using the Oxford classification system at Soonchunhyang University Hospital, Seoul, Korea. All cases were categorized according to Lee's classification. Renal biopsies from all patients were scored by a pathologist who was blinded to the clinical data for pathological variables. Inclusion criteria were age greater than 18 years and at least 36 months of follow-up. We excluded cases with secondary IgAN, diabetic nephropathy combined other glomerulopathies, less than 36 months of follow-up, and those that progressed rapidly.

          Results

          The median age of the patients was 34 years (range, 27 to 45). Mean arterial blood pressure was 97 ± 10 mmHg at the time of biopsy. The median follow-up period was 85 months (range, 60 to 114). Kaplan-Meier analysis showed significant prognostic predictions for M, E, and T lesions. A Cox proportional hazard regression analysis also revealed prognostic predictions for E and T lesions.

          Conclusions

          Using the Oxford classification in IgAN, E, and T lesions predicted renal outcome in Korean adults after taking clinical variables into account.

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          Histologic subclassification of IgA nephropathy: a clinicopathologic study of 244 cases.

          Christine M. Haas (1997)
          IgA nephropathy (IgAN) may present with a wide variety of histologic patterns on renal biopsy, ranging from a minimal lesion to a diffuse proliferative glomerulonephritis (GN). The histologic features of 244 cases of IgAN (not including Schönlein-Hanoch nephritis) diagnosed between 1980 and 1994 were reviewed, and each case was subclassified using the following, relatively simple histologic classification scheme: subclass I (39 cases): minimal or no mesangial hypercellularity, without glomerular sclerosis; subclass II (18 cases): focal and segmental glomerular sclerosis without active cellular proliferation; subclass III (110 cases): focal proliferative GN; and subclass IV (42 cases): diffuse proliferative GN; and subclass V (35 cases): any biopsy showing > or = 40% globally sclerotic glomeruli and/or > or = 40% estimated cortical tubular atrophy or loss. Subsequent analysis of renal survival in 109 patients who underwent biopsy before or during 1992 for whom such data were available showed a strong, statistically significant correlation between histologic subclass and renal survival, with an order I, II (greatest survival) > III > IV, V. Crescents were a significant negative prognostic indicator for renal survival in subclass III (but not in subclass IV), and interstitial expansion was a negative prognostic indicator in subclasses III and IV, although the statistical significance of these were not maintained after controlling for serum creatinine at the time of biopsy. The presence of peripheral glomerular capillary deposits ultrastructurally had no prognostic significance. With respect to clinical presentation, hypertension (systolic blood pressure > or = 130 mm Hg and diastolic blood pressure > or = 90 mm Hg) and proteinuria of > or = 2.0 g/24 hr were significant negative prognostic indicators for renal survival, even when controlling for serum creatinine at the time of renal biopsy. The presence of gross hematuria correlated significantly with increased renal survival by univariate analysis, but not when controlling for serum creatinine at the time of renal biopsy. The findings of this study confirm the wide variety of clinical and histopathologic presentations of IgAN, and indicate the utility of the proposed histologic classification schema in assessing a patient's likelihood of ultimately developing end-stage renal disease.
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            Validation of the Oxford classification of IgA nephropathy.

            Nuket Bavbek, Michelle Hladunewich, Fernando Fervenza … (2011)
            The Oxford classification of IgA nephropathy (IgAN) identified four pathological elements that were of prognostic value and additive to known clinical and laboratory variables in predicting patient outcome. These features are segmental glomerulosclerosis/adhesion, mesangial hypercellularity, endocapillary proliferation, and tubular atrophy/interstitial fibrosis. Here, we tested the Oxford results using an independent cohort of 187 adults and children with IgAN from 4 centers in North America by comparing the performance of the logistic regression model and the predictive value of each of the four lesions in both data sets. The cohorts had similar clinical and histological findings, presentations, and clinicopathological correlations. During follow-up, however, the North American cohort received more immunosuppressive and antihypertensive therapies. Identifying patients with a rapid decline in the rate of renal function using the logistic model from the original study in the validation data set was good (c-statistic 0.75), although less precise than in the original study (0.82). Individually, each pathological variable offered the same predictive value in both cohorts except mesangial hypercellularity, which was a weaker predictor. Thus, this North American cohort validated the Oxford IgAN classification and supports its utilization. Further studies are needed to determine the relationship to the impact of treatment and to define the value of the mesangial hypercellularity score.
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              A scoring system to predict renal outcome in IgA nephropathy: from a nationwide prospective study.

              Kenji Wakai, Yoshiyuki Ohno, Masayuki Endoh … (2006)
              Immunoglobulin A (IgA) nephropathy is the most common form of glomerulonephritis in the world, and a substantial number of patients develop end-stage renal disease (ESRD). Although there are several prognostic indicators, it remains difficult to predict the renal outcome in individual patients. A prospective cohort study was conducted in 97 clinical units in Japan from 1995 to 2002. We analysed the data from 2269 patients using proportional hazards models in order to determine the predictors of ESRD in IgA nephropathy and to develop a scoring system to estimate ESRD risk. During the follow-up (median, 77 months), 207 patients developed ESRD. Systolic hypertension, proteinuria, hypoproteinaemia, azotaemia and a high histological grade at initial renal biopsy were independently associated with the risk of ESRD. Mild haematuria predisposed patients to ESRD more than severe haematuria. A scoring system was developed to estimate the 7-year ESRD risk from eight clinical and pathological variables. Actually, this prognostic score accurately classified patients by risk: patients with estimates of 0.0-0.9, 1.0-4.9, 5.0-19.9, 20.0-49.9, and 50.0-100.0% had a 0.2, 2.4, 12.2, 40.2 and 80.8% of ESRD incidence over 7 years, respectively. The corresponding area under the receiver operating characteristic curve was 0.939 [95% confidence interval (CI), 0.921-0.958]. This score was verified in repetitions of the derivation-validation technique. Although the quality of some data collected by the mail survey is limited and the influence of therapy could not be considered, this scoring system will serve as a useful prognostic tool for IgA nephropathy in clinical practice.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Intern Med
                Journal ID (iso-abbrev): Korean J. Intern. Med
                Journal ID (publisher-id): KJIM
                Title: The Korean Journal of Internal Medicine
                Publisher: The Korean Association of Internal Medicine
                ISSN (Print): 1226-3303
                ISSN (Electronic): 2005-6648
                Publication date (Print): September 2012
                Publication date (Electronic): 01 September 2012
                Volume: 27
                Issue: 3
                Pages: 293-300
                Affiliations
                [1 ]Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea.
                [2 ]Hyon Am Kidney Laboratory, Soonchunhyang University Hospital, Seoul, Korea.
                [3 ]Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea.
                [4 ]Department of Pathology, Soonchunhyang University Hospital, Seoul, Korea.
                Author notes
                Correspondence to Soon Hyo Kwon, M.D. Department of Internal Medicine, Hyon Am Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea. Tel: 82-2-709-9029, Fax: 82-2-709-9554, ksoonhyo@ 123456schmc.ac.kr
                Article
                DOI: 10.3904/kjim.2012.27.3.293
                PMC ID: 3443722
                PubMed ID: 23019394
                SO-VID: 26522b6e-59c3-4acd-b850-25410f851a59
                Copyright © Copyright © 2012 The Korean Association of Internal Medicine
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 23 September 2011
                Date revision received : 07 November 2011
                Date accepted : 21 December 2011
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Internal medicine
                Keywords: glomerulonephritis,histology,iga,prognosis
                Data availability:
                ScienceOpen disciplines: Internal medicine
                Keywords: glomerulonephritis, histology, iga, prognosis

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