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Multicenter Study
. 2017 Feb;28(2):691-701.
doi: 10.1681/ASN.2016040433. Epub 2016 Sep 9.

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

Mark Haas  1 , Jacobien C Verhave  2 , Zhi-Hong Liu  3 , Charles E Alpers  4 , Jonathan Barratt  5 , Jan U Becker  6 , Daniel Cattran  7 , H Terence Cook  8 , Rosanna Coppo  9 , John Feehally  5 , Antonello Pani  10 , Agnieszka Perkowska-Ptasinska  11 , Ian S D Roberts  12 , Maria Fernanda Soares  13 , Hernan Trimarchi  14 , Suxia Wang  15 , Yukio Yuzawa  16 , Hong Zhang  17 , Stéphan Troyanov  18 , Ritsuko Katafuchi  19
Affiliations
Multicenter Study

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

Mark Haas et al. J Am Soc Nephrol. 2017 Feb.

Erratum in

  • Erratum.
    [No authors listed] [No authors listed] J Am Soc Nephrol. 2017 May;28(5):1665. doi: 10.1681/ASN.2017020168. J Am Soc Nephrol. 2017. PMID: 28455358 Free PMC article. No abstract available.

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 mean±SD eGFR of 78±29 ml/min per 1.73 m2 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 one fourth or more of glomeruli), identifying patients at even greater risk of progression, even with immunosuppression.

Keywords: IgA nephropathy; Oxford classification; Renal pathology; crescents; glomerulonephritis.

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Figures

Figure 1.
Figure 1.
Distribution of the percentage of glomeruli with crescents in biopsies with any crescents. Crescents were present in 1118 (36%) of 3096 total biopsies.
Figure 2.
Figure 2.
Associations between the presence and fraction of glomeruli with crescents and the subsequent use of immunosuppression. Total numbers of biopsies in each category of crescents are given in parentheses; the total number of biopsies was 3096.
Figure 3.
Figure 3.
Univariate effect of the fraction of glomeruli with crescents on the rate of renal function decline in all patients, patients not receiving immunosuppression, and those receiving immunosuppression. Data shown are means with 95% CIs; 2% of individuals had no reported rate of renal function decline and are not included in the analysis.
Figure 4.
Figure 4.
Univariate effect of the presence and fraction of glomeruli with crescents on survival from a combined event in all patients, patients not receiving immunosuppression, and those receiving immunosuppression. Each curve represents patients with biopsies showing the indicated fraction of crescents. Numbers of patients without and with any crescents are listed at baseline and after 2, 4, 6, 8 and 10 years of follow-up.
Figure 5.
Figure 5.
Adjusted HRs of a combined event using different fractions of glomeruli with crescents in all patients, patients not receiving immunosuppression, and those receiving immunosuppression. HRs are in reference to no crescents and adjusted for the MEST scores, initial eGFR, and time-averaged MAP and proteinuria. C+, with crescents.
See this image and copyright information in PMC

Comment in

  • Glomerular disease: Crescents in IgAN.
    Allison SJ. Allison SJ. Nat Rev Nephrol. 2016 Nov;12(11):650. doi: 10.1038/nrneph.2016.141. Epub 2016 Sep 26. Nat Rev Nephrol. 2016. PMID: 27665928 No abstract available.

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