IntroductionAmong various lupus renal vascular changes, thrombotic microangiopathy (TMA) presented with the most severe clinical manifestations and high mortality. The pathogenesis of TMA in systemic lupus erythematosus (SLE) was complicated. The aim of this study was to assess clinical manifestations, laboratory characteristics, pathological features and risk factors for clinical outcomes of lupus nephritis patients co-existing with renal TMA in a large cohort in China.MethodsClinical and renal histopathological data of 148 patients with biopsy-proven lupus nephritis were retrospectively analyzed. Serum complement factor H, A Disintegrin and Metalloprotease with Thrombospondin type I repeats 13 (ADAMTS-13) activity, antiphospholipid antibodies and C4d deposition on renal vessels were further detected and analyzed.ResultsIn the 148 patients with lupus nephritis, 36 patients were diagnosed as co-existing with renal TMA based on pathological diagnosis. Among the 36 TMA patients, their clinical diagnoses of renal TMA were as followings: 2 patients combining with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome, 2 patients combining with anti-phospholipid syndrome, 2 patients with malignant hypertension, 1 patient with scleroderma and the other 29 patients presenting with isolated renal TMA. Compared with the non-renal TMA group, patients with renal TMA had significantly higher urine protein (7.09 ± 4.64 vs. 4.75 ± 3.13 g/24h, P = 0.007) and serum creatinine (159, 86 to 215 vs. 81, 68 to 112 μmol/l, P <0.001), higher scores of total activity indices (AI) (P <0.001), endocapillary hypercellularity (P <0.001), subendothelial hyaline deposits (P = 0.003), interstitial inflammation (P = 0.005), glomerular leukocyte infiltration (P = 0.006), total chronicity indices (CI) (P = 0.033), tubular atrophy (P = 0.004) and interstitial fibrosis (P = 0.018). Patients with renal TMA presented with poorer renal outcome (P = 0.005) compared with the non-TMA group. Renal TMA (hazard ratio (HR): 2.772, 95% confidence interval: 1.009 to 7.617, P = 0.048) was an independent risk factor for renal outcome in patients with lupus nephritis. The renal outcome was poorer for those with both C4d deposition and decreased serum complement factor H in the TMA group (P = 0.007).ConclusionsThere were various causes of renal TMA in lupus nephritis. Complement over-activation via both classical and alternative pathways might play an important role in the pathogenesis of renal TMA in lupus nephritis.

BackgroundProblem-based learning (PBL), a pedagogical approach, is widely accepted in medical education. Manipulated by many factors, the internal motivation of learner is the most crucial determinant that affects the nature of the outcome, in which the influences of critical thinking (CT) remained elusive.MethodsOne hundred two third-year undergraduate medical students at Peking University were involved in this study. A Chinese version of the Critical Thinking Disposition Inventory (CTDI-CV) was used to assess the CT disposition, and the performance scores of students in PBL tutorials were compiled. A parametric bivariate correlation analysis was performed between the students’ CT scores and their PBL average scores. The PBL scores were compared between the strong and weak CT disposition groups using independent t-test. The analysis of numerical data was conducted using SPSS 16.0.ResultsCT disposition of third-year undergraduate medical students at Peking University was at a positive level, with an average score of 297.72. The total CT scores had a positive correlation with the scores of the PBL performance and its five dimensions significantly. In the majority, students with Strong-CT disposition obtained higher scores in PBL tutorials compared with students with Weak-CT disposition. The performance of these two groups was significantly different in the Late-Half but not in the Early-Half PBL tutorials. Furthermore, a significant improvement was observed in the students with strong CT but not weak CT dispositions.ConclusionCT disposition positively correlates to a students’ PBL performance. Students with stronger CT dispositions perform better in the PBL process and obtain higher scores. Our work suggested that the open-mindedness of the CT disposition is the primary factor that determines the improvement of the preparation dimensions in the PBL process.

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