Prediction of urinary protein markers in lupus nephritis

BACKGROUND: Lupus nephritis is divided into six classes and scored according to activity and chronicity indices based on histologic findings. Treatment differs based on the pathologic findings. Renal biopsy is currently the only way to accurately predict class and activity and chronicity indices. We propose to use patterns of abundance of urine proteins to identify class and disease indices. METHODS: Urine was collected from 20 consecutive patients immediately prior to biopsy for evaluation of lupus nephritis. The International Society of Nephrology/Renal Pathology Society (ISN/RPS) class of lupus nephritis, activity, and chronicity indices were determined by a renal pathologist. Proteins were separated by two-dimensional gel electrophoresis. Artificial neural networks were trained on normalized spot abundance values. RESULTS: Biopsy specimens were classified in the database according to ISN/RPS class, activity, and chronicity. Nine samples had characteristics of more than one class present. Receiver operating characteristic (ROC) curves of the trained networks demonstrated areas under the curve ranging from 0.85 to 0.95. The sensitivity and specificity for the ISN/RPS classes were class II 100%, 100%; III 86%, 100%; IV 100%, 92%; and V 92%, 50%. Activity and chronicity indices had r values of 0.77 and 0.87, respectively. A list of spots was obtained that provided diagnostic sensitivity to the analysis. CONCLUSION: We have identified a list of protein spots that can be used to develop a clinical assay to predict ISN/RPS class and chronicity for patients with lupus nephritis. An assay based on antibodies against these spots could eliminate the need for renal biopsy, allow frequent evaluation of disease status, and begin specific therapy for patients with lupus nephritis.     

Interobserver reproducibility and application of the ISN/RPS classification of lupus nephritis-a UK-wide study

We sought to assess the interobserver variation of the new International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification of lupus nephritis when compared with the previous World Health Organization classification, when used by pathologists throughout the UK. We also sought differences in how the 2 classifications were applied to a single set of biopsies. Twenty unselected renal biopsies showing lupus nephritis were circulated to pathologists in the UK National Renal Pathology External Quality Assessment Scheme, before the ISN/RPS scheme was published, with a request to apply the World Health Organization classification. The same slides were recirculated approximately 1 year later with a request to apply the ISN/RPS classification. A significant improvement in interobserver reproducibility was demonstrated by the new classification (kappa 0.53 vs. 0.44, P = 0.002). The reproducibility of the assessment of disease activity and chronicity remains suboptimal (kappa = 0.33). The new classification tends to produce more diagnoses of Class IV lupus nephritis, with fewer diagnoses of Classes III and V. The improvement in interobserver reproducibility indicates that an important aim of the new classification has been achieved. Further work is needed to determine whether the increase in diagnosis of Class IV nephritis represents an improvement in biopsy interpretation or a divergence from the previous classification, as the latter could undermine attempts to relate results from the new system to treatment strategies based on clinical trials which used the old.     

The efficacy and safety of immunosuppressive agents plus steroids compared with steroids alone in the treatment of Henoch–Schönlein purpura nephritis: A meta-analysis

Background

Henoch–Schönlein purpura nephritis (HSPN) is the most severe symptom of Henoch–Schönlein purpura. The role of immunosuppressive agents combined with steroids is controversial in treating HSPN. Our meta-analysis was performed to assess the efficacy and safety of the combined therapy in the treatment of HSPN compared with steroids alone.

Methods

Cochrane Library, Pubmed, Embase, and Web of Science were searched and Newcastle–Ottawa Scale was used to assess the quality of the literatures. Odds ratios (OR) and standard mean difference (SMD) with a 95% confidence interval (CI) were used for dichotomous and continuous variables. A random-effect model or fixed-effect analysis was applied according to heterogeneity.

Results

A total of 9 articles were selected in our study. HSPN patients treated with combined therapy demonstrated a significant increase in complete remission rates (OR?=?1.95; 95% CI 1.17–3.23, P?=?0.010) and total remission rates (OR?=?2.30 95% CI 1.33–3.98, P?=?0.003) when compared with steroids alone. Children seemed to benefit more from combined treatment (OR?=?2.45; CI 1.20–5.02, P?=?0.014) than adults (OR?=?1.56; CI 0.76–3.20, P?=?0.225). Additionally, immunosuppressants plus steroids had an advantage on decreasing proteinuria (SMD?=?0.28; CI 0.05–0.52, P?=?0.019) and increasing the level of serum albumin (SMD?=?0.98; CI 0.35–1.60, P?=?0.002). However, significant differences were not found in the estimated glomerular filtration rate (eGFR) and rates of side-effects.

Conclusion

Administration of immunosuppressive agents combined with steroids may be a superior alternative for HSPN. Nevertheless, long-term, high-quality, large-sample, and multicenter RCTs are required to make the results more convincing.

     

Clinicopathological insights into lupus glomerulonephritis in Japanese and Asians

Lupus nephritis comprises a spectrum of glomerular, vascular, and tubulointerstitial lesions, which has significant racial variation in severity and manifestations. The current classification (ISN/RPS 2003) has been improved successfully for the categorization of lupus glomerulonephritis (LGN). On the basis of this classification, 480 Japanese cases revealed the following distribution: class I 3%, class II 16%, class III 13%, class IV-S 11%, class IV-G 41%, class V 16%, and class VI 1%. Class IV-G with chronicity tended to have the worst renal outcome. Nephrotic syndrome was a more frequent complication in class IV-S (50%), class IV-G (72%), and class V (56%), with poor renal and actuarial outcomes. With regard to therapy, treatment options including glucocorticoids alone or combined with antimetabolites (azathioprine, mizoribine, mycophenolate mofetil), calcineurin inhibitors (cyclosporine A, tacrolimus), or alkylating agents (intravenous cyclophosphamide injection) improved the outcome of LGN; however, there is no high-grade clinical evidence from Japan. Further studies are needed to resolve the clinicopathological problems of LGN, especially IV-S, IV-G, and pure membranous lupus nephritis in Japanese patients.     

The prognosis and pathogenesis of severe lupus glomerulonephritis.

BACKGROUND: The International Society of Nephrology/ Renal Pathology Society classification (ISN/RPS) of lupus glomerulonephritis (GN) divides diffuse GN (>/=50% involvement) into diffuse segmental (IV-S) and diffuse global GN (IV-G). This division tests whether the pathogenesis and clinical outcomes are the same as when similar patients are classified using the World Health Organization (WHO) classification into severe segmental (WHO III >/=50%) and diffuse global (WHO-IV) GN. METHODS: Thirty-nine renal biopsies with WHO class IV and 44 with WHO III >/= 50% were reclassified using the ISN/RPS and were correlated with pathogenesis and outcome. RESULTS: There were 22 biopsies with ISN/RPS class IV-S. ISN/RPS class IV-G comprises two morphologically discrete classes of renal biopsies: 39 biopsies originally classified as WHO class IV (WHO-IV) and 22 that switched from WHO III >/=50% to ISN/RPS class IV-G (IV-Q). We will analyze IV-S, IV-Q and WHO-IV separately. WHO-IV had significantly more immune aggregate deposition than IV-S and IV-Q. WHO-IV had lower serum complements C3 (P = 0.05) and C4 (P = 0.05) than patients with IV-Q. Patients with WHO-IV had more remissions (56%) than IV-Q (23%) (P = 0.01), and stable renal function at the last follow-up was less frequent in patients with IV-Q (18%) than IV-S (50%, P = 0.05) and WHO-IV (62%, P = 0.001). Renal survival and renal survival without end-stage renal disease were different when the patients were diagnosed as WHO classes III >/=50% and IV, but the outcomes for ISN/RPS class IV-S and IV-G (WHO-IV plus IV-Q) were not different. CONCLUSIONS: WHO III >/=50% and WHO-IV lupus GN are not congruent with ISN/RPS IV-S and IV-G. The ISN/RPS minimizes pathological and outcome differences between classes IV-S and IV-G which results in the loss of informational content from the renal biopsies. ISN/RPS does not detect pathogenetic or clinical differences among patients with severe lupus GN.     

Efficacy and safety of tacrolimus versus corticosteroid as initial monotherapy in adult-onset minimal change disease: a meta-analysis

Objective

The objective of this meta-analysis was to compare the efficacy and safety of tacrolimus (TAC) monotherapy versus corticosteroid as initial monotherapy in adult-onset minimal change disease (MCD) patients.

Methods

Databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang database were searched from the inception to March 20, 2021. Eligible studies comparing TAC monotherapy and corticosteroid as initial monotherapy for adult-onset MCD patients were included. Data were analyzed using Review Manager Version 5.3.

Results

Four randomized controlled trials (RCTs) involving 196 patients were included in the meta-analysis. For initial monotherapy for adult-onset MCD, TAC and corticosteroid had similar complete remission (OR 1.06, 95% CI 0.47–2.41, P?=?0.89), total remission (OR 1.30, 95% CI 0.39–4.35, P?=?0.67), relapse rate (OR 0.63, 95% CI 0.28–1.42, P?=?0.26). Main drug-related adverse effects of two therapeutic regimens had no difference concerning infection (OR 0.54, 95% CI 0.23–1.27, P?=?0.15), glucose intolerance (OR 0.55, 95% CI 0.16–1.84, P?=?0.33) and acute renal failure (OR 1.37, 95% CI 0.36–7.31, P?=?0.71).

Conclusion

TAC monotherapy is comparable with corticosteroid monotherapy in initial therapy of MCD. To further confirm the conclusion, more large multicenter RCTs are necessary.

     

Atteintes rénales du lupus

Systemic lupus erythematosus is the most characteristic of auto-immune disorders that can lead to tissue damage in many organs, including kidney. Lupus nephritis occurs in 10 to 40% of lupus patients. Its clinical hallmark is the appearance of a proteinuria as soon as a 0.5 g/g or 0.5 g/d threshold, which calls for a renal histological evaluation in order to determine the lupus nephritis severity and the need for specific therapy. More than half of renal biopsies lead to the diagnosis of active lupus nephritis–class III or class IV A according to the ISN/RPS classification–that are the most severe in regards to renal prognosis and mortality. Their treatment aims to their clinical remission and to the prevention of relapse with minimal adverse effects for eventually the preservation of renal function, the prevention of other irreversible damage, and the reduction of risk of death. The remission is obtained through induction therapies of which the association of high dose steroids and cyclophosphamide is the most experienced. When this association must be challenged by the prevention of side-effect, in particular infertility, mycophenolate can be given instead of cyclophosphamide. Maintenance therapy, for the prevention of relapse, consists in mycophenolate or in azathioprine, mycophenolate being the most efficient however associated with a high risk of teratogenicity. Withdrawal of maintenance therapy is possible after two to three years in absence of high risk factors of relapse of lupus nephritis, however a reliable assessment of the risk of relapse is still lacking. Only pure membranous lupus nephritis (pure class V) associated with high level proteinuria requires specific therapies that usually associates steroids and an immunosuppressive drug. However, their choice hierarchy and even the use of less immunosuppressive strategies remain to be determined in terms of benefice over risk ratios. In spite of its trigger effect on lupus activity, pregnancy can be safe and successful if scheduled in the lowest risk periods with close multidisciplinary monitoring before, during and after. When necessary, renal replacement therapy does not require specific adaptation, renal transplantation is the best option when possible, as early as possible.     

The ISN/RPS 2003 classification of lupus nephritis: an assessment at 3 years

The 2003 International Society of Nephrology (ISN)/Renal Pathology Society (RPS) Classification of lupus nephritis (LN) was designed to eliminate ambiguities and standardize definitions. Major changes from the 1982 Modified WHO Classification include the elimination of the normal biopsy category and the subcategories of membranous Class V, the introduction of sharper distinctions between the classes, and the addition of subcategories within diffuse LN (class IV) for predominantly segmental (LN IV-S) and global (LN IV-G) lesions. It stipulates that sclerotic glomeruli owing to scarred LN should be taken into account when assessing the percentage of glomeruli affected by LN. Since its publication, the ISN/RPS classification has been used successfully in a number of clinical-pathologic studies. Several studies addressing the relationship between LN IV-S and LN IV-G have failed to identify a significantly worse outcome in IV-S than IV-G, although there were some differences in presenting clinical and pathologic features. Importantly, the ISN/RPS classification has achieved its goal of improved interobserver reproducibility. Its use has increased the percentage of LN biopsies meeting criteria for class IV. As it gains widespread acceptance, the ISN/RPS classification is already providing a standardized approach to renal biopsy interpretation needed to compare outcome data across centers.     

Toll-like receptor 9 SNPs are susceptible to the development and progression of membranous glomerulonephritis: 27 years follow-up in Taiwan

Abstract

The purpose of this study was to determine whether toll-like receptors 9 (TLR9) gene polymorphisms (rs352139 and rs352140) were markers of susceptibility to the development and progression of membranous nephropathy (MGN) in Taiwanese patients. The polymorphisms were investigated by polymerase chain reaction in 397 Taiwanese individuals (134 MGN patients and 263 controls). Patients with malignancy, chronic infectious diseases, lupus nephritis, or drug-induced secondary MGN were excluded from the study. Data showed AA genotype at rs352139 SNP or GG genotype at rs352140 SNP may indicate higher risk for MGN (odds ratio [OR]?=?1.55; 95% confidence interval [CI]?=?1.02–2.35, at rs352139 SNP; OR?=?1.57; 95% CI?=?1.03–2.39, at rs352140 SNP). However, MGN patients with A–G haplotype were susceptible for decreased creatinine clearance rate and for seriously tubule-interstitial fibrosis. The result suggests for the first time that TLR9 (rs352139 and rs352140) polymorphisms may contribute to the development and progression of MGN.     

Prediction model for cardiovascular disease risk in hemodialysis patients

Purpose

To derive and validate a prediction score for cardiovascular disease (CVD) risk in hemodialysis patients in China.

Methods

Three hundred and eighty-eight patients with regular hemodialysis for more than 3 months were recruited from January 1, 2015 to September 30, 2019 and followed up till May 31, 2020. We derived a prediction score using all participants as a training data set and validated using a bootstrap validation data set. Discriminatory ability of the prediction score was assessed by the area under the receiver operating characteristic curve (AUC).

Results

Of 388 patients without CVD at baseline, 132 developed first CVD events during an average follow-up of 3.27 (inter-quartile range?=?3.08) years. Of 26 clinical parameters, age, hypertension, diabetes and abnormal white blood cell (WBC) count were identified as significant predictors and included in the prediction model. Compared to those without any of these risk factors, those with one, two, and three to four points showed increased risks of CVD, with the adjusted hazards ratio and 95% confidence interval (CI) being 3.29 (1.17–9.26), 7.42 (2.68–20.51) and 15.43 (5.44–43.75), respectively. The score showed satisfactory discriminatory ability in both training and validation data set (AUC?=?0.7025, 95% CI 0.6520–0.7530, and 0.6876, 95% CI 0.6553–0.7200, respectively).

Conclusion

We derived and validated a prediction score for CVD risk in hemodialysis patients in China. Given there is a rapid increase in the number of hemodialysis patients, this simple point score can be used to identify high-risk individuals in clinical practice for more precise and efficient personalized treatment.

     

Anti-pentraxin 3 auto-antibodies might be protective in lupus nephritis: a large cohort study

Objectives: Anti-pentraxin 3 (PTX3) auto-antibodies were found to be associated with the absence of renal involvement in systemic lupus erythematosus (SLE). This study is to investigate the prevalence of anti-PTX3 auto-antibodies and their clinical significance based on a large Chinese lupus nephritis cohort.

Methods: One hundred and ninety-six active lupus nephritis patients, 150 SLE patients without clinical renal involvement, and 100 healthy controls were enrolled. Serum anti-PTX3 auto-antibodies and PTX3 levels were screened by enzyme-linked immunosorbent assay (ELISA). The associations between anti-PTX3 auto-antibodies and clinicopathological parameters in lupus nephritis were further analyzed.

Results: Anti-PTX3 auto-antibodies were less prevalent in active lupus nephritis patients compared with SLE without renal involvement (19.4% (38/196) versus 40.7% (61/150), p?r?=??.143, p?=?.047). The levels of proteinuria, serum creatinine, and the prevalence of thrombotic microangiopathy were significantly higher in patients with higher PTX3 levels (≥3.207?ng/ml) and without anti-PTX3 auto-antibodies compared with patients with lower PTX3 levels (<3.207?ng/ml) and with anti-PTX3 auto-antibodies (4.79 (3.39–8.28) versus 3.95 (1.78–7.0), p?=?.03; 168.84?±?153.63 versus 101.44?±?47.36, p?=?.01; 34.1% (14/41) versus 0% (0/9), p?=?.04; respectively).

Conclusion: Anti-PTX3 auto-antibodies were less prevalent in active lupus nephritis patients compared with SLE without renal involvement and associated with less severe renal damage, especially with the combined evaluation of serum PTX3 levels.     

Association of angiotensin-converting enzyme insertion/deletion polymorphism with type 1 diabetic nephropathy: a meta-analysis

Objective: This study aimed to systematically evaluate the effect of an angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene polymorphism on type 1 diabetic nephropathy (DN).

Methods: Cochrane Library, Embase, PubMed, Science Direct, Web of science, Wanfang data, VIP database, China Knowledge Resource Integrated Database, and SinoMed were searched. A total of 17 case–control studies analyzing ACE I/D polymorphism and type 1 DN risk were included in the present meta-analysis.

Results: Overall, a significant increased risk was found in allele comparison (OR?=?1.16, 95% CI?=?1.05–1.28, p?=?0.04), dominant comparison (OR?=?1.56, 95% CI?=?1.14–2.15, p?=?0.006) and homozygote comparison (OR?=?1.52, 95% CI?=?1.06–2.19, p?=?0.02). In subgroup analyses according to ethnicity, the risk of type 1 DN in Asian population was increased in allele comparison (OR?=?1.98, 95% CI?=?1.15–3.42, p?=?0.01), recessive comparison (OR?=?2.48, 95% CI?=?1.51–4.10, p?=?0.0004), dominant comparison (OR?=?3.15, 95% CI?=?1.90–5.23, p?p?=?0.05). However, there was no association between the ACE I/D genetic variants and type 1 DN in Caucasian populations.

Conclusions: Our meta-analysis results indicate that the ACE I/D polymorphism may contribute to type 1 DN development, especially in the Asian groups with type 1 diabetes. The current findings need to be confirmed by future well-designed and larger sample size primary studies in populations with different ethnicities.     

Recurrent acute kidney injury in elderly patients is common and associated with 1-year mortality

Background

Acute kidney injury (AKI) is common among elderly patients after a first hospitalized AKI. Patients who recover are at risk for recurrence, but recurrent geriatric AKI is not well-studied.

Methods

This was a retrospective, 12-month cohort study using data from the National Clinical Research Center for Geriatric Diseases. Recurrent AKI was defined as a new spontaneous rise of?≥?0.3 mg/dl (≥?26.5 µmol/L) within 48 h or a 50% increase in serum creatinine (Scr) from the baseline within 7 days after the previous AKI episode. The outcome measured was 12-month mortality.

Results

Among 1711 study patients, 652 developed AKI. Of the 429 AKI survivors in whom recovery could be assessed, 314 patients recovered to their baseline renal function, and 115 patients developed chronic kidney disease (CKD). Of the group that recovered renal function, 90 patients (28.7%) subsequently developed recurrent AKI, while 224 (71.3%) did not. Of the 429 survivors with AKI, 103 patients (24.0%) died within 12 months. Multivariate logistic regression analysis revealed that recurrent AKI was significantly associated with coronary disease (odds ratio [OR?=?2.008; 95% confidence interval [CI] 1.024–3.938; P?=?0.042), a need for mechanical ventilation (OR?=?2.265; 95% CI 1.267–4.051; P?=?0.006) and high blood urea nitrogen levels (OR?=?1.036; 95% CI 1.002–1.072; P?=?0.040) at the first AKI event. Kaplan–Meier curves showed the 12-month survival of patients with non-recurrent AKI was better than that of patients with CKD, and survival of patients with recurrent AKI was worse than that of patients with CKD (log rank P?<?0.001). In the multivariate Cox regression analysis, mortality at 12 month was higher in the patient with recurrent AKI as compared with those with a single episode (HR?=?3.375; 95% CI 2.241–5.083; P?<?0.001).

Conclusion

Recurrent AKI is common among elderly patients who recovered their renal function post-AKI and is associated with significantly higher 12-month mortality compared with CKD patients.

     

The effect of histopathologic and clinical features on allograft survival in renal transplant patients with antibody-mediated rejection

Background: Antibody-mediated rejection is a frequent cause of graft failure; however, prognostic indications of this complication have not been well defined. The aim of this study was to evaluate the association of histopathological and clinical features and to determine the effect of these findings on allograft survival in patients with AMR.

Methods: Fifty-two patients suffered from AMR (30 male; mean age 39?±?11 years) were included in the study. Data were investigated retrospectively and graft survival was analyzed. All transplant biopsies were evaluated according to Banff 2009 classification.

Results: Of the 52 cases, 45 were transplanted from living-donors. Twenty-one patients were diagnosed in the first 3-months after transplantation. Graft survival was 65% at 12 months and 54% at 36 months. Mean serum creatinine at time of biopsy was 3.8?±?3.6?mg/dL. Thirty-five of the 52 cases showed diffuse C4d positivity, 12 cases showed focal and 5 remained C4d negative. One of the patients died, 13 experienced graft loss and 38 survived with functioning grafts. Serum creatinine levels at time of biopsy were correlated with graft survival (p?=?.021: OR?=?1.10: 95 % CI?=?1.015–1.199). In terms of the impact of pathological findings; tubulitis (p=.007: OR?=?2.62: 95 % CI?=?1.301–5.276), intimal arteritis (p=.017: OR?=?2.85: 95% CI?=?1.205–6.744) and interstitial infiltration (p=.004: OR?=?3.37: 95% CI?=?1.465–7.752) were associated with graft survival.

Conclusions: Serum creatinine at time of biopsy, tubulitis, intimal arteritis and interstitial infiltration were significantly associated with graft survival. Antibody-mediated rejection is associated with reduced long-term graft survival.     

Feasibility of E-PASS score to predict postoperative complications in laparoscopic nephrectomy

Purpose

To evaluate the usefulness of E-PASS score to predict postoperative complications after laparoscopic nephrectomy.

Methods

Between 2008 and 2020, 424 patients (179 patients: simple nephrectomy, 158 patients: radical nephrectomy, 87 patients: donor nephrectomy) who underwent laparoscopic nephrectomy in our clinic, were included in the study. Patient groups separated according to the presence of postoperative complications were compared retrospectively regarding demographic, clinical, intraoperative, and postoperative data, comorbidities, and E-PASS scores (PRS, SSS, and CRS). The relationship between postoperative complications and E-PASS scores was examined.

Results

Postoperative complications occurred in 43 (10.1%) of the patients. Age, previous abdominal/retroperitoneal surgery, radical nephrectomy rate of surgeries, operation time, amount of bleeding, need for blood transfusion, rate of conversion from laparoscopic surgery to open surgery, hospitalization time, E-PASS PRS, SSS, and CRS were statistically significantly higher in the group with postoperative complications. The cutoff value of the E-PASS CRS was ? 0.2996 to predict the development of postoperative complications (AUC?=?0.706; 95% CI 0.629–0.783; p?<?0.001). According to multivariate analysis, presence of previous abdominal/retroperitoneal surgery (OR?2.977; 95% CI?1.502–5.899; p?=?0.002), laparoscopic radical nephrectomy (OR?2.518; 95% CI?1.224–5.179; p?=?0.012), conversion from laparoscopic surgery to open surgery (OR?4.869; 95% CI?1.046–22.669; p?=?0.044) and E-PASS CRS?>?? 0.2996 (OR?2.816; 95% CI?1.321–6.004; p?=?0.007) were found to be independent risk factors predicting postoperative complications.

Conclusion

The E-PASS scoring system is an effective and convenient system for predicting postoperative complications after laparoscopic nephrectomy.

     

Treating severe Henoch-Schönlein and IgA nephritis with plasmapheresis alone

The aim of our study was to determine the outcome of children with severe Henoch-Schönlein nephritis (HSN) and immunoglobulin A (IgA) nephritis (IgAN) treated with early plasmapheresis alone. Children with acute renal impairment, heavy proteinuria or both and histology greater than grade 3 were treated with early plasmapheresis alone. Glomerular filtration rate (GFR) estimated from plasma creatinine (eGFR), urine albumin:creatinine ratio (UA/UC) and blood pressure 2 weeks after treatment and were measured at the last follow-up. Sixteen children (14 HSN, 2 IgAN) had a mean eGFR of 56 (17–136) ml/min per 1.73 m² and UA/UC of 590 (12–1,379) mg/mmol. Fifteen were referred at presentation and one after 2 months, and all commenced plasmapheresis within 6 (2–13) days. All had at least nine exchanges of 90 ml/kg over 2 weeks. At 2 weeks, the eGFR had increased by 51 (95% CI 34–68; P?=?0.002), and the UA/UC fell by 457 (95% CI 241–673; P?=?0.0001). At last review after 4 (1–7.5) years, the late-referred child had required a renal transplant but the other 15 had normal eGFRs (98–142), did not require hypotensive medication, and had normal or minimally elevated UA/UC (maximum 42). Children with severe HSN and IgAN recover well if treated with plasmapheresis alone without the need for immunosuppressive therapy. A randomised trial is needed.     

Efficacy and safety of glucocorticoids for patients with IgA nephropathy: a meta-analysis

Background

The efficacy and safety of glucocorticoids for the treatment of patients with IgA nephropathy (IgAN) remains controversial. The aim of the study is to perform a metaanalysis of randomized controlled trials to evaluate the efficacy and safety of glucocorticoids for patients with IgAN.

Methods

We searched PubMed, EMBASE and the Cochrane Library and article reference lists of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing glucocorticoids with other non-immunosuppressive agents in patients with IgAN.

Results

The present meta-analysis, including 10 RCTs and 791 patients from 12 published studies, showed that using glucocorticoids agents relatively preserves kidney function(RR 0.06, 95% CI 0.14–0.61) and plays an effective role on reducing the proteinuria(SMD, ??0.69; 95% CI 0.85 to ??0.53, p?<?0.00001; heterogeneity I2?=?0%; p?=?0.09) compared with a control group. Moreover, adverse events cannot be neglected, especially gastrointestinal tract (RR 3.10, 95% CI 1.37–6.98, p?=?0.006; heterogeneity I2?=?0%, p?=?0.86), and corticosteroid regimens in IgAN should be reviewed with regard to safety.

Conclusions

Glucocorticoids were wildly used to treat various diseases including IgAN. Meanwhile, adverse events cannot be neglected, such as gastrointestinal adverse events, infection and so on. Corticosteroid should be used with reserve, especially in those patients with hypertension and impaired renal function or older patients.

     

Laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for treatment of large renal pelvic calculi (diameter >2 cm): a meta-analysis

Objective: To systematically assess the efficacy and safety of laparoscopic pyelolithotomy (LP) versus percutaneous nephrolithotomy (PCNL) for the treatment of renal pelvic calculi >2?cm.

Methods: We searched PubMed, Embase, Cochrane Library, and Google Scholar about LP and PCNL for the treatment of renal stones. The retrieval time ended in September 2015. Two reviewers independently assessed the quality of all included studies. The available data in the studies were analyzed using the RevMan 5.2 software.

Results: Four randomized controlled trials (RCTs) and nine Non-Randomized Concurrent Controlled Trials (NRCCTs) were included, involving a total of 766 patients. This meta-analysis showed that LP has a statistically higher stone-free rate than PCNL [I^2?=?0, OR?=?0.26 (95% CI 0.10–0.64), p?=?0.003], lower drop in hemoglobin level [I^2?=^?0, difference in mean drop?=??0.83 (95% CI ?1.05 to ?0.61), p?I^2?=^?0, OR?=?0.36 (95% CI 0.14–0.89), p?=?0.03], and PCNL is associated with a lower length of hospital stay [I^2?=^?74%, difference in mean of hospital stay?=?0.72 (95% CI 0.04–1.40), p?=?0.04].

Conclusion: LP is an alternative for the treatment of large solitary renal stone. LP may have a higher stone-free rate, lesser blood loss, lower postoperation fever rate, while PCNL may have a lower length of hospital stay. However, further well designed and large volume randomized controlled trials are needed to confirm these findings.