Class IV-S Research Articles

Application of Micro Earth Pressure Cells to Geomechanical Model Tests of Arch Dams

Geomechanical model tests are important in the evaluation of the stability of engineering rock masses, and they play a key role in the stability studies on arch dam abutments. To further analyze the instability failure process and mechanical characteristics of dam abutment rock masses, this study employed a stress monitoring system in the traditional strain and displacement monitoring to improve the comprehensiveness of test results. With their advantageous properties, including their small volume, high sensitivity, and strong stability, micro earth pressure cells can directly monitor stress changes in arch abutment rock mass during geochemical model tests. On the basis of the overloading method, this study applied micro earth pressure cells to a 2D geomechanical model test on the Yebatan arch dam to investigate the working performance of the arch dam and arch abutment at EL.2 750 m. In the test, the surface displacement monitoring system and micro earth pressure cells on both sides of the deep unloading belts of the left and right dam abutments were arranged to study the pressure changes at the arch abutment and the influence of the geological structure. The results showed that the measured stress value near the arch abutment was large and that the measured stress value greatly decreased after passing through the deep unloading belt. Class IVs of strongly relaxed rock masses in the left abutment exerted an obvious attenuation effect on the arch thrust while fault f29 (f74) greatly influenced the right abutment. The results were verified by the displacement test data. The application of micro earth pressure cells facilitated the direct observation and analysis of dam abutment stress and improved the completeness of the test results. Thus, the proposed approach provides a new idea for geomechanical model tests.

Lupus Nephritis Class IV-Global Is Associated with a Higher Risk of End-Stage Renal Disease than Class IV-Segmental

Introduction: The International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification of lupus nephritis (LN) divides class IV into segmental and global (IV-S and IV-G) based on evidence suggesting different renal outcomes. However, subsequent studies have shown conflicting results. Objective: This study was performed to compare long-term renal outcomes between the IV-S and IV-G classes. Methods: This is a retrospective cohort study of adult patients with biopsy-proven class IV LN using the ISN/RPS classification. The primary end point was end-stage renal disease (ESRD). Results: Among the 89 patients, rapidly progressive glomerulonephritis was twice as frequent in the IV-G group (60 vs. 29%; p = 0.005) than that in the IV-S group. Moreover, the IV-G group had a higher rate of biopsy with cellular and fibrocellular crescents (70.9 vs. 47.1%, p = 0.024) and more crescentic glomerulonephritis (34.5 vs. 5.8%, p = 0.007) than the IV-S group. After a mean follow-up of 57 months, the IV-G group had a greater risk of ESRD (RR 3.9; 95% CI 1.2–12.2, p = 0.006) than the IV-S group. Multivariate analysis indicated that class IV-G was an independent predictor of ESRD. Conclusions: Patients with class IV-G have a higher risk of ESRD than patients with class IV-S.

Experimental and numerical analyses on working performance of a high arch dam with deep-seated joints: Yebatan arch dam, China

High arch dams commonly face complicated geological conditions at the dam site, which is particularly prominent in numerous projects in the southwest mountainous area of China. The deep-seated joint is a special geological defect caused by unloading fracturing of the deep rock mass, which is unfavourable to the working performance of high arch dam projects. The Yebatan arch dam is a world-class high arch dam, situated in a deeply carved V-shaped gorge with deep-seated joint zones in both banks. In this paper, both geomechanical model test and numerical analysis are carried out to study the working performance of the Yebatan arch dam and abutment, which are affected by the deep-seated joint zones. The research results demonstrate that the deep-seated joint zones have a significant effect on the arch dam and abutment working performance. It is highly dependent on the location of the class IVS strong relaxed rock mass and the combination with faults. The class IVS strong relaxed rock mass in the left abutment has a great impact on the deformation of arch dam and abutment, and fault f29 (f74) plays a dominant role in controlling the anti-sliding stability of the right abutment. Subsequently, a kind of concrete replacement measure is proposed in order to treat these project weaknesses. The additional numerical analysis results indicate the deformation and stability performance of arch dam and abutment are greatly improved after reinforced. The reinforcement measure is effective for Yebatan project.

Revision of the International Society of Nephrology/Renal Pathology Society classification for lupus nephritis: clarification of definitions, and modified National Institutes of Health activity and chronicity indices

We present a consensus report pertaining to the improved clarity of definitions and classification of glomerular lesions in lupus nephritis that derived from a meeting of 18 members of an international nephropathology working group in Leiden, Netherlands, in 2016. Here we report detailed recommendations on issues for which we can propose adjustments based on existing evidence and current consensus opinion (phase 1). New definitions are provided for mesangial hypercellularity and for cellular, fibrocellular, and fibrous crescents. The term "endocapillary proliferation" is eliminated and the definition of endocapillary hypercellularity considered in some detail. We also eliminate the class IV-S and IV-G subdivisions of class IV lupus nephritis. The active and chronic designations for class III/IV lesions are replaced by a proposal for activity and chronicity indices that should be applied to all classes. In the activity index, we include fibrinoid necrosis as a specific descriptor. We also make recommendations on issues for which there are limited data at present and that can best be addressed in future studies (phase 2). We propose to proceed to these investigations, with clinicopathologic studies and tests of interobserver reproducibility to evaluate the applications of the proposed definitions and to classify lupus nephritis lesions.

Do ANCAs make the difference in lupus nephritis?

There has been much debate as to whether the distinction between lupus nephritis class IV-S and class IV-G is clinically relevant and whether antineutrophil cytoplasmic antibodies are pathomechanistically involved because they have been associated with the more necrotic and pauci-inflammatory phenotype of lupus nephritis that is more often seen in class IV-S. Recent data show that antineutrophil cytoplasmic antibody positivity indeed influences the histological pattern of lupus nephritis and is associated with worse baseline renal function and more active lupus serology.

The clinico-pathological features of lupus nephritis and the significance of ISN/RPS-2003 Class IV lesions

Background: The ISN/RPS-2003 classification of lupus nephritis should emphasize clinically relevant lesions and encourage uniformity and reproducibility in histopathological reporting. Objective: To describe the clinico-pathological features of lupus nephritis and discuss the significance of the ISN/RPS-2003 class IV-G and IV-S lesions. Method: The histopathological features and corresponding clinical data of 75 patients with lupus nephritis were analysed using the International Society of Nephrology/Renal Pathology Society ISN/RPS - 2003 classification. This was a retrospective descriptive study carried out over a period of two and a half years at the Department of Pathology, Faculty of Medicine, Colombo. Results and conclusions: Lupus nephritis was commoner in females (88%, 66/75), with 52%, (36/75) in the 21-30 year age group. ANA positivity (93%, 70/75) was the commonest ACR (American College of Rheumatology - 1997) criterion to clinically diagnose SLE. Asymptomatic sub-nephrotic proteinuria was found in 47% (35/75), nephrotic syndrome in 21% (16/75) and hypertension in 17% ( 13/75). Endocapillary proliferation 84% (63/75) and wire-loop lesions 51% (38/75) were found to be the commonest histological features. 79% (59/75) had ISN/RPS class IV lupus nephritis (diffuse lupus nephritis) with the majority 93% (55/75) belonging to class IV-G (predominantly diffuse global lesions) and the remainder to class IV-S (predominantly segmental lesions). The pathogenesis of class IV-G lesions is thought to be immune complex mediated where as class 1V-S lesions are thought to show injury analogous to systemic vasculitides, unrelated to immunologic injury. Data on the prognostic outcomes of the two groups is conflicting because class IV-G is morphologically heterogenous, with two prognostically and pathogenetically distinct subcategories. Journal of Diagnostic Pathology 2014; 9(2): 14-22

Prognosis of proliferative lupus nephritis subsets in the Louvain Lupus Nephritis inception Cohort

The objective of this paper is to evaluate whether the different International Society of Nephrology/Renal Pathology Society (ISN/RPS) classes of proliferative lupus nephritis (LN) have a distinct baseline presentation, short-term response to immunosuppression (IS) and long-term prognosis. Ninety-eight patients with new onset (first renal biopsy) ISN/RPS proliferative LN (Class III: n=24; IV-S: n=23; IV-G: n=51) were diagnosed at our institution between 1995 and 2012 (Louvain Lupus Nephritis inception Cohort). Their baseline renal parameters, primary response to IS at one year, survival and long-term renal outcome (mean follow-up: 77 months) were compared. At baseline, serum creatinine and 24-hour proteinuria were higher in Class IV-G, as was activity index on renal biopsy in Class IV-S and IV-G compared to III. Upon treatment, renal parameters improved with the same kinetics and to the same extent in the three pathological classes. On repeat renal biopsies (n=43), activity indices dropped similarly. Poor outcomes (death, end-stage renal disease, renal impairment defined by an eGFR <60 ml/min/1.73 m(2)) did not statistically differ between groups, although there was a trend toward more renal impairment at follow-up in Class IV-G compared to IV-S and III. Finally, the presence of even mild chronic lesions on baseline biopsy was clearly predictive of late renal outcome. Subsetting proliferative LN into Class III, IV-S and IV-G provides less clinically discriminant prognostic information than baseline chronicity index.

Rare transformation in repeat renal biopsies suggests a different pathogenesis of segmental and global lesions in proliferative lupus nephritis

Heterogeneous histological findings in the renal biopsies of patients with systemic lupus erythematosus were distinguished early into different types of lupus nephritis with different outcomes. The effort to unify the terminology resulted in six classes of the World Health Organization (WHO) classification published in 1982 [1]. Having apart biopsies with normal histology (Class I) and advanced sclerotic lesions (Class VI), it became apparent that there are two main types of lupus nephritis: membranous (Class V) and proliferative (Classes III and IV), although there were also patients with a combination of both membranous and proliferative lesions. Membranous lupus nephritis was shown early to have better outcome than proliferative lupus nephritis, but the relation between focal (Class III) and diffuse (Class IV) lesions remained uncertain. Segmental lesions typical for Class III lupus nephritis resemble the lesions present in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and are very different from global lesions typical for Class IV which, on the other hand, may resemble the immune complex-mediated lesions present, e.g. in idiopathic membranoproliferative glomerulonephritis. According to the new International Society of Nephrology/Renal Pathology Society (ISN/RPS) histological classification [1] segmental lesions may be present both in Class III (focal lupus nephritis) if affecting 50% of glomeruli. The ISN/RPS Class IV category thus mixes together segmental lesions in >50% of glomeruli (Class IV-S) and diffuse proliferative lesions (Class IV-G) affecting >50% of glomeruli [2]. Although some authors argued that focal segmental lesions may evolve into diffuse global lesions and both of them may regress (after treatment) into mesangial (Class II) lupus nephritis, other authors referred that there are significant differences between WHO Classes III and IV (and ISN/RPS Class IV-S and IV-G) lupus nephritis both concerning the histological characteristics, clinical presentation and outcome, and that the pathogenesis of segmental and global proliferative lesions may be different [3]. In this issue of NDT Pagni et al. evaluated 142 patients with lupus nephritis and repeat biopsies. Although their original main aim was to look at the role of repeat renal biopsies in routine clinical practice, their paper also adds an important contribution to our understanding of the putatively different pathogenesis of different histological classes of (proliferative) lupus nephritis. Patients with IV-G class of lupus nephritis had, at presentation compared with segmental forms of lupus nephritis (Classes III and IV-S), higher proteinuria, serum creatinine and blood pressure and more mesangial proliferation, wire loops and tuft necrosis in the biopsy. The disease was more severe in both first and repeat biopsy in Class IV-G compared with Class III and IV-S patients and repeat renal biopsy predicted better trend of serum creatinine and proteinuria than the first biopsy. Most importantly, although the transitions between different histological classes were quite frequent (40.8%), the transition between segmental (III/IV-S) and mesangial (II/IV-G) forms was extremely rare, strongly suggesting that really both forms may have not only different clinical and histological features, but also different pathogenesis. Important differences in the histology between IV-G and IV-S patients were repeatedly (and relatively consistently) described. Patients with IV-S class had, compared with IV-G class, e.g. fewer glomeruli with wire loops [3, 4] and hyalin thrombi [3], more frequent fibrinoid necrosis [4–7], lower endocapillary proliferation [6], significant trend to the higher proportion of crescents [4], less frequent infiltration of glomeruli with monocyte/macrophages, lower interstitial inflammation [6] and less IgG (or even complete absence of IgG) on immunofluorescence [3]. Histologic differences may be translated into some differences in the clinical presentation. Class IV-G lupus nephritis was shown to present, compared with Class IV-S, with higher serum creatinine, worse proteinuria [4–6] and higher diastolic blood pressure [4, 7] and also lower C3 [5, 6] and lower proportion of patients with the positivity of anticardiolipin antibodies [6]. Patients with Class III were also shown to have a lower prevalence of the positivity of anti-C1q compared with Class IV patients [8] and patients with segmental lesions (Classes III and IV-S) have the lowest levels of complement factor H in SLE and lupus nephritis patients [9]. IN F O C U S

OP0062 Lupus nephritis histopathology interobserver agreement between local pathologists and an expert panel of nephropathologists in belong

BackgroundStudies have shown that assessing renal histopathology for lupus nephritis is subject to interobserver variability.1,2 Local pathologists’ readings of lupus nephritis biopsies are commonly used to determine entry into multicenter...

THU0323 Subsettting Proliferative Lupus Nephritis According to the ISN/RPS Classification Does not Provide Valuable Prognostic Information

ObjectivesTo evaluate, including through repeated renal biopsy, whether the different ISN/RPS classes of proliferative lupus nephritis (LN) have similar short- and long-term responses to immunosuppression and have distinct long-term prognosis.MethodsNinety-eight...

Reconstruction of Orbitomaxillary Defects

Defects of the orbitomaxillary complex are problematic, not only for the patient, who deals with physical and psychological sequelae of his or her condition, but also for the surgeon, who must select from numerous treatment options to achieve the best possible outcome. As is often the case in surgically managed disease states, there is minimal high-level evidence to direct decision making in this area of medicine. We aim with this case series to at least provide our perspective on orbitomaxillary reconstruction based on a single-surgeon's 6-year experience at the University of Florida in Jacksonville. A chart review was performed for patients treated by the maxillofacial surgery division from August 2006 through August 2011, who underwent reconstruction of orbitomaxillary defects (Classes III to VI) resulting from ablative surgery. Data collected included patient demographics, surgery performed, reconstructive methods, pathology, and adjuvant radiotherapy. Inclusion criteria consisted of an initial surgery involving maxillectomy with orbital involvement performed at our institution, adequate follow-up, and complete medical records. Patients treated elsewhere or with inadequate records were excluded from the study. We identified 21 patients who met the criteria for this study. Their ages ranged from 44 to 79 years, with 8 men and 13 women. Histologic evaluation showed squamous cell carcinoma in the majority of cases (14 patients). All defects were either Brown Class III, IV, V, or VI with the distribution as follows: 7 Class IIIs, 5 Class IVs, 7 Class Vs, and 2 Class VIs. The reconstructions included 8 radial forearm flaps, 4 anterolateral thigh flaps, 2 thoracodorsal artery perforator fasciocutaneous flaps, 1 thoracodorsal angular artery composite flap, 2 latissimus dorsi myofasciocutaneous flaps, and 1 composite fibula flap. Three patients had only an obturator with local flaps or skin grafting. Of the 21 patients, 18 had postoperative radiation. Follow-up ranged from 2 to 60 months. Three patients died of their disease, 14 were alive without disease, and 4 were lost to follow-up. Mean follow-up was 24.5 months. On the basis of our patient experience, we believe that we can offer the following perspective: patients reconstructed for these larger defects, Classes III to VI, were less likely to be discontented with their reconstruction as compared with those who underwent obturation. The choice of bone versus soft tissue-only reconstruction was not a significant issue for our patient population because the vast majority of patients were not interested in dental implants because of out-of-pocket costs. In the era of perforator flaps, we believe that the use of these flaps provides a more predictive outcome compared with musculocutaneous flaps, which will atrophy over time and lead to a change in facial contour.

Segmental and Global Subclasses of Class IV Lupus Nephritis Have Similar Renal Outcomes

Whether renal outcomes differ between the segmental and global subclasses of diffuse proliferative (class IV) lupus nephritis is unknown. In this meta-analysis, we searched the literature in MEDLINE, EMBASE, five registries of clinical trials, and selected cohort studies and randomized, controlled trials that used the 2003 International Society of Nephrology and Renal Pathology Society classification of lupus nephritis in adult patients. Our endpoint was the composite of doubling of serum creatinine concentration or ESRD. In the eight studies included in the final analysis, the incidence of this endpoint varied between 0% and 67%. A funnel plot and Egger's test did not suggest significant heterogeneity. The meta-analysis did not support a significant difference in renal outcome between the segmental (IV-S) and global (IV-G) subclasses (relative risk for class IV-G versus IV-S, 1.08; 95% confidence interval, 0.68-1.70). Meta-regression did not suggest that ethnicity or duration of follow-up influenced the association between histologic class and renal risk. In conclusion, the rate of doubling of serum creatinine concentration or of ESRD did not differ between patients with class IV-S and those with IV-G lupus nephritis.

Clinical and Morphologic Differences between Class IV-S and Class IV-G Lupus Nephritis

Introduction. The new ISN/RPS classification of lupus nephritis (LN) divides diffuse proliferative LN into two subcategories with predominantly segmental proliferative lesions (class IV-S) and with predominantly global proliferative lesions (class IV-G). This paper explores the validity of this distinction and possible differences between the two types of lesions. Patients and Methods. A retrospective analysis of biopsy-proven cohort of 231 patients with LN was performed. Clinical and laboratory data were available on all patients selected. Results. The prevalence of Class IV was 27,27% (41 patients had class IV-S, 22-class IV-G). The serum creatinine levels, proteinuria, and diastolic blood pressure were significantly greater in the IV-G class, but haemoglobin was significantly lower. Histologically combined lesions with segmental endocapillary proliferation and fibrinoid necrosis were more frequent in the class IV-S. No significant difference was detected in outcomes in the two groups after followups of 145,2 ± 76,87 months. Conclusions. There are definite clinical and morphologic differences between class IV-S and IV-G lesions. Data suggest that class IV-G lesions behave as an immune complex disease; however, in class IV-S lesions, the presence of proportionally greater glomerular fibrinoid necroses suggests that these lesions may have a different pathogenesis.

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.

Outcome of reclassification of World Health Organization (WHO) class III under International Society of Nephrology-Renal Pathology Society (ISN-RPS) classification: retrospective observational study

The outcome of systemic lupus erythematosus (SLE) is largely influenced by the existence of lupus nephritis (LN), and its histologic classification guides the treatment and prognosis of SLE. International Society of Nephrology-Renal Pathology Society (ISN-RPS) announced a revised classification of LN in 2004. The present study investigated the differential outcome of World Health Organization (WHO) class III LN when reclassified according to ISN-RPS classification. Forty-three patients with biopsy-proven WHO class III LN at a single tertiary hospital were included in the study. Baseline characteristics at the time of renal biopsy and clinical data during follow-up were obtained from medical records. Renal response to treatment at one-year follow-up was analyzed in three ways; complete response (CR), partial response (PR), and no response (NR). Of 43 patients with previous WHO class III LN, 12 cases were reclassified into ISN-RPS class IV (9 cases of class IV-S and 3 cases of IV-G). Baseline characteristics at the time of renal biopsy were not different between the reclassified class IV and remaining class III LN group except activity index on renal histology, which was significantly elevated in the reclassified class IV group (4.90 vs. 6.75; P = 0.02). Significantly higher number of patients with remaining class III LN achieved CR to treatment than those with reclassified class IV LN at one-year follow-up since initial biopsy (CR: PR: NR; 16:7:7 vs. 3:1:8; P = 0.032). Our study suggests that the ISN-RPS classification is more advantageous in predicting renal outcome and guiding treatment when evaluating previously classified WHO class III LN.

Characteristics and influence factors of pathologic transformation in the subclasses of class IV lupus nephritis

The study explored the characteristics and correlation factors of transformation in subclasses of class IV lupus nephritis. Patients with class IV lupus nephritis were subjected to repeat biopsies after 6months of induction treatment. Transformation rate between two subclasses, class IV-S and class IV-G, was compared. Influence Factors of transformation were evaluated. Class IV-G had more severe hypertension and higher score of immunofluorescence index, glomerular active lesions, tubular and vascular lesions. Class IV-S had a higher percentage of glomerular fibrinoid necrosis. Class IV-S appeared a higher rate of transformation to class II than class IV-G (57% vs. 27%). In each subclass, active lesion also showed a higher rate of transformation to class II than active/chronic lesion (IV-G: 41.2% vs. 12.5%; IV-S: 71.4% vs. 42.8%). Patients who maintained class IV had higher blood pressure, obvious proteinuria, declined kidney function, and lower C3 level. Immunosuppressive therapy, urine protein, and vascular lesions were independent risk factors for the pathologic transformation. The rate of transformation in class IV-S was higher than that in class IV-G. The transformation is most likely to benefit from immunosuppressive therapy. Urine protein and vascular lesions are correlated with the transformation in class IV lupus nephritis.

Class IV-G and IV-S lupus nephritis in Chinese patients: a large cohort study from a single center

This study is to assess the difference between IV-G and IV-S in a large cohort of Chinese patients with lupus nephritis. The detailed data of patients with subclass IV-G and IV-S were retrospectively analyzed. Serum ANCA and anti-C1q antibodies were detected. A total of 172 cases were classified as class IV, including 152 cases with IV-G and 20 cases with IV-S. In IV-S, the level of haemoglobin was significantly higher (P = 0.024), proteinuria was milder (P = 0.003), serum creatinine was lower (P = 0.021), serum C3 was higher (P = 0.045) and the ratio of positive serum anti-cardiolipin antibodies was higher (P = 0.014). On pathological evaluation, the ratio of glomerular fibrinoid necrosis was significantly higher (P = 0.006) and the score of endocapillary hypercellualrity, interstitial inflammation and total activity indices was significantly lower (P < 0.001, P = 0.01, P = 0.006, respectively) in IV-S. The frequency of serum ANCA was significantly higher in IV-S than that in IV-G (20 vs 4.6%, P = 0.008). The frequencies of anti-C1q IgG1 and IgG3 subclass were significantly higher in IV-G (P = 0.006, P = 0.011, respectively). There are significant differences in clinical and pathological manifestations between IV-S and IV-G lupus nephritis which need further investigation.

Classification of lupus nephritis

Lupus nephritis manifests as diverse patterns of immune complex-mediated renal disease affecting glomerular, tubulointerstitial, and vascular compartments. This review will focus on the most recent classification, the 'International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 Classification of Lupus Nephritis', and will briefly discuss other types of renal disease seen in patients with systemic lupus erythematosus. The ISN/RPS 2003 Classification of lupus nephritis includes multiple changes from its predecessors, most notably removal of the subclasses of lupus nephritis class V (i.e. Va-Vd), elimination of the normal category (WHO class I), clearer definitions for all classes, a standard approach to sclerotic glomeruli, and the division of lupus nephritis class IV into subcategories based on whether the endocapillary involvement is predominantly segmental (lupus nephritis IV-S) or global (lupus nephritis IV-G). These changes have led to a higher level of interobserver reproducibility and a significant increase in the number of cases of class IV, with a reciprocal decline in lupus nephritis class III and lupus nephritis class V. Multiple studies have found that lupus nephritis class IV-S has similar or better outcomes than lupus nephritis class IV-G. The ISN/RPS 2003 classification of lupus nephritis is gaining widespread acceptance and appears to be achieving its goals of reproducibility and clinical relevance.

Revised classification of lupus nephritis is valuable in predicting renal outcome with an indication of the proportion of glomeruli affected by chronic lesions

To determine if the International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification of lupus nephritis (LN) is helpful in predicting renal outcome. A total of 92 patients with LN who underwent renal biopsy in our hospital were re-classified according to the ISN/RPS 2003 criteria. The mean patient age was 36.8 yrs and the median observation period was 65 months. The relative frequency for each class was as follows: Class I (minimal mesangial LN) 0%, Class II (mesangial proliferative LN) 13%, Class III (focal LN) 17%, Class IV (diffuse LN) 60% and Class V (membranous LN) 10%. Within Class IV, diffuse segmental (Class IV-S) was 25% and diffuse global (Class IV-G) 75%. During the observation period, renal function was more likely to deteriorate in Class IV-G cases than in Class IV-S cases. Importantly, when Class IV-G was subdivided into cases involving active lesion alone [IV-G (A)] or chronic lesion [IV-G (A/C)], the majority of cases in IV-G (A) was nephrotic, but responded well to therapy. In contrast, renal function declined only in IV-G (A/C) cases. Patients with Class IV-G (A/C) had persistent proteinuria in spite of intensified therapies. Moreover, the higher proportion of chronic lesions was related with the deterioration of renal function. This study showed that in Class IV-G cases, renal outcome differed in the presence of chronicity. Chronicity could be a critical factor in predicting outcome. Thus, the revised classification of LN is clinically valuable in identifying different renal outcomes among patients with diffuse LN.

The difference between lupus nephritis class IV-G and IV-S in Koreans: focus on the response to cyclophosphamide induction treatment

To evaluate the response to induction therapy with intravenous (i.v.) cyclophosphamide (CYC) in Korean patients with class IV-G (diffuse global proliferative glomerulonephritis) and class IV-S (diffuse segmental proliferative glomerulonephritis) lupus nephritis (LN) according to the classification system of the International Society of Nephrology/Renal Pathology Society (ISN/RPS). Of the 52 patients with biopsy-proven diffuse proliferative LN, who had been treated with i.v. CYC over a 10-yr period, 42 had been treated with i.v. CYC (equal to or more than 500 mg) for 6 consecutive months and had biopsy specimens containing more than nine glomeruli. The renal pathology of these 42 patients was reclassified according to the International Society of Nephrology and the Renal Pathology Society 2003 classification, and their renal response rates and laboratory indices after induction therapy were analysed. Of the 42 patients assessed, 30 (71%) had IV-G and 12 (29%) had IV-S. Pre-treatment 24 h urinary protein was significantly higher and pre-treatment concentration of anti-dsDNA antibody was significantly lower in IV-G than in IV-S patients. Following induction therapy, complete remission rates were significantly higher in patients with IV-S (67%, 8/12) than in patients with IV-G (33%, 10/30) LN. Class IV-G LN responded more poorly to induction therapy with i.v. CYC pulse than class IV-S LN.