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      Evaluating a New International Risk-Prediction Tool in IgA Nephropathy

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          IgA nephropathy.

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            Remission of proteinuria improves prognosis in IgA nephropathy.

            Proteinuria has been shown to be an adverse prognostic factor in IgA nephropathy. The benefit of achieving a partial remission of proteinuria, however, has not been well described. We studied 542 patients with biopsy-proven primary IgA nephropathy in the Toronto Glomerulonephritis Registry and found that glomerular filtration rate (GFR) declined at -0.38 +/- 0.61 ml/min per 1.73 m2/mo overall, with 30% of subjects reaching end-stage renal disease. Multivariate analysis revealed that proteinuria during follow-up was the most important predictor of the rate of GFR decline. Among the 171 patients with 3 g/d (n = 121) lost renal function 25-fold faster than those with or =3 g/d who achieved a partial remission (<1 g/d) had a similar course to patients who had < or =1 g/d throughout, and fared far better than patients who never achieved remission. These results underscore the relationship between proteinuria and prognosis in IgA nephropathy and establish the importance of remission.
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              Validation of the Oxford classification of IgA nephropathy in cohorts with different presentations and treatments

              The Oxford Classification of IgA Nephropathy (IgAN) identified mesangial hypercellularity (M), endocapillary proliferation (E), segmental glomerulosclerosis (S), and tubular atrophy/interstitial fibrosis (T) as independent predictors of outcome. Whether it applies to individuals excluded from the original study and how therapy influences the predictive value of pathology remain uncertain. The VALIGA study examined 1147 patients from 13 European countries that encompassed the whole spectrum of IgAN. Over a median follow-up of 4.7 years, 86% received renin–angiotensin system blockade and 42% glucocorticoid/immunosuppressive drugs. M, S, and T lesions independently predicted the loss of estimated glomerular filtration rate (eGFR) and a lower renal survival. Their value was also assessed in patients not represented in the Oxford cohort. In individuals with eGFR less than 30 ml/min per 1.73 m2, the M and T lesions independently predicted a poor survival. In those with proteinuria under 0.5 g/day, both M and E lesions were associated with a rise in proteinuria to 1 or 2 g/day or more. The addition of M, S, and T lesions to clinical variables significantly enhanced the ability to predict progression only in those who did not receive immunosuppression (net reclassification index 11.5%). The VALIGA study provides a validation of the Oxford classification in a large European cohort of IgAN patients across the whole spectrum of the disease. The independent predictive value of pathology MEST score is reduced by glucocorticoid/immunosuppressive therapy.
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                Author and article information

                Journal
                JAMA Internal Medicine
                JAMA Intern Med
                American Medical Association (AMA)
                2168-6106
                April 13 2019
                Affiliations
                [1 ]Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
                [2 ]BC Renal, Vancouver, British Columbia, Canada
                [3 ]Regina Margherita Children’s University Hospital, Torino, Italy
                [4 ]Peking University Institute of Nephrology, Beijing, China
                [5 ]Nanjing University School of Medicine, Nanjing, China
                [6 ]Faculty of Medicine, Juntendo University, Tokyo, Japan
                [7 ]National Fukuoka Higashi Medical Center, Fukuoka, Japan
                [8 ]Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
                [9 ]The John Walls Renal Unit, Leicester General Hospital, Leicester, England
                Article
                10.1001/jamainternmed.2019.0600
                © 2019

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