Clinical course of Immunoglobulin A nephropathy with crescents in a multi‐ethnic Southeast Asian cohort

Abstract

AimClinical presentation and course of Immunoglobulin A nephropathy vary by ethnicity and geography and significance of extracapillary proliferation or crescents (IgAN‐C) in Southeast Asia is not well described. We aimed to describe the clinical course of IgAN‐C in Singapore.MethodsRetrospective cohort study of adult biopsy‐proven IgAN diagnosed between February 2011 and October 2016 in 2 hospital‐based nephrology units. Outcome was chronic kidney disease (CKD) progression, defined as reduction in eGFR ≥50% or end stage renal failure (ESRF).ResultsOne hundred and forty‐five patients were studied. Among individuals with IgAN‐C (n = 44, 30%), 38 patients had cellular or fibrocellular crescents in 1 to 25% of the glomeruli and 6 had crescents in >25%. Median eGFR was 54 (33, 83) mL/min/1.73 m2. Compared to IgAN without crescents, IgAN‐C had greater proteinuria (median 2.9 [1.4, 5.4] g/g vs 1.9 [1.1, 3.6] g/g, P = .03) and more had endocapillary hypercellularity (96% vs 39%, P < .001). IgAN‐C were also more likely to receive immunosuppressants (66% vs 43%, P = .01) such as prednisolone (63% vs 38%, P = .006) and cyclophosphamide (12% vs 2%, P = .03).Median follow up was 27 (12, 46) months. IgAN‐C were more likely to achieve proteinuria reduction ≥50% at 6 months (66% vs 44%, P = .03). CKD progression within 12 months was not different among those with and without crescents (13% vs 10% respectively, P = .73). However, immunosuppressant treatment of IgAN‐C was associated with reduced ESRF (0 vs 20%, P = .03).ConclusionImmunosuppressants may attenuate the risk of ESRF in IgAN‐C.

Efficacy and Safety of Glycosides of Tripterygium wilfordii Combined with Renin-Angiotensin System in the Treatment of IgA Nephropathy: A Systematic Review and Meta-Analysis

“…Primary IgA nephropathy is more common, accounting for about 36.7% to 58.2% of primary glomerular diseases diagnosed by renal pathology in China, and its incidence has been gradually increasing in recent years [1,2]. It can be seen at any age, and patients aged 16-35 years account for about 80% of the total number of patients with the disease [3,4].…”

Crescents in kidney biopsy – What do they imply? A clinicopathologic study of 40 cases in a tertiary care center

“…In a recent study, crescents in IgA nephropathy were not found to be statistically associated with increased probability of progression to end-stage renal disease. [ 15 ]…”

Individualizing immunosuppressive therapy decision in immunoglobulin A nephropathy and application in a Southeast Asian cohort

“…Kidney histology in the form of the Oxford MEST-C score can prognosticate kidney failure in IgAN [ 3 ], but its role in guiding immunosuppression remains uncertain [ 4 ]. We previously reported that among our multi-ethnic Southeast Asians with biopsy-proven IgAN with crescents, immunosuppressive therapy tended to lower the risk of rapid kidney disease progression [50% reduction in estimated glomerular filtration rate (eGFR) or kidney failure at 12 months] and significantly reduced kidney failure [ 5 ]. While other studies have also explored the impact of immunosuppressants on kidney outcomes according to the presence and extent of crescents [ 6 , 7 ], Itami et al .…”

“…In our dataset of 66 IgAN with complete clinical and histological data [ 5 ], SRS were low, medium and high in 4 (6%), 33 (50%) and 29 patients (44%), respectively. The median age was 46.8 (interquartile range 36.6, 58.5) years and systolic and diastolic blood pressures were 128 (119, 140) and 71 (70, 80) mmHg, respectively.…”

“…It is therefore timely that the proposed Clinical Study in IgA nephropathy (CLIgAN) trial will consider histological activity, in addition to kidney function and proteinuria, to individualize treatment decisions [ 10 ]. As current knowledge is based on data from the pre-sodium glucose co-transporter-2 inhibitors (SGLT2i) era [ 5 , 7 , 9 ], future immunosuppressant trials for IgAN with active histological lesions will also need to consider if optimized RASB and SGLT2i will alter the benefit conferred by immunosuppression.…”