A Multicenter Study of the Predictive Value of Crescents in IgA Nephropathy

Abstract

The Oxford Classification of IgA nephropathy does not account for glomerular crescents. However, studies that reported no independent predictive role of crescents on renal outcomes excluded individuals with severe renal insufficiency. In a large IgA nephropathy cohort pooled from four retrospective studies, we addressed crescents as a predictor of renal outcomes and determined whether the fraction of crescent-containing glomeruli associates with survival from either a $50% decline in eGFR or ESRD (combined event) adjusting for covariates used in the original Oxford study. The 3096 subjects studied had an initial mean6SD eGFR of 78629 ml/min per 1.73 m 2 and median (interquartile range) proteinuria of 1.2 (0.7-2.3) g/d, and 36% of subjects had cellular or fibrocellular crescents. Overall, crescents predicted a higher risk of a combined event, although this remained significant only in patients not receiving immunosuppression. Having crescents in at least one sixth or one fourth of glomeruli associated with a hazard ratio (95% confidence interval) for a combined event of 1.63 (1.10 to 2.43) or 2.29 (1.35 to 3.91), respectively, in all individuals. Furthermore, having crescents in at least one fourth of glomeruli independently associated with a combined event in patients receiving and not receiving immunosuppression. We propose adding the following crescent scores to the Oxford Classification: C0 (no crescents); C1 (crescents in less than one fourth of glomeruli), identifying patients at increased risk of poor outcome without immunosuppression; and C2 (crescents in over one fourth of glomeruli), identifying patients at even greater risk of progression, even with immunosuppression.

Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group

“…Crescents were also found to be predictive of poor renal outcomes in several other studies including patients with eGFR <30 ml/min 12,13 31 . Therefore, we propose that the Oxford classification should now involve five components, MEST-C rather than MEST.…”

“…Since cases of Henoch-Schönlein purpura nephritis were excluded from the recent study of crescents in IgAN 31 , we recommend the MEST-C score not to be applied to cases of Henoch-Schönlein purpura nephritis yet.…”

Serum Matrix Metalloproteinase-7 Level is Associated with Fibrosis and Renal Survival in Patients with IgA Nephropathy

“…A recent large IgAN cohorts revealed that crescents predicted a higher risk of 50% decline in eGFR or ESRD in patients without receiving immunosuppression [29]. Moreover, having crescents in at least one fourth of glomeruli independently related with a combined event in patients, no matter receiving immunosuppression or not.…”

<b><i>Campylobacter rectus</i></b> in the Oral Cavity Correlates with Proteinuria in Immunoglobulin A Nephropathy Patients

“…The Oxford classification was proposed by the Working Group of the International IgA Nephropathy Network and it has gained worldwide acceptance [25-27]. We compared the renal histology of C. rectus -positive and -negative groups of IgAN patients using the Oxford classification in a blind test.…”