狼疮肾炎活检中与间质纤维化和肾小管萎缩（IFTA）及血管损伤相关的临床特征和肾脏预后。
Clinical characteristics and renal prognosis associated with interstitial fibrosis and tubular atrophy (IFTA) and vascular injury in lupus nephritis biopsies.
机构信息
Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
出版信息
Semin Arthritis Rheum. 2019 Dec;49(3):396-404. doi: 10.1016/j.semarthrit.2019.06.002. Epub 2019 Jun 11.
BACKGROUND
Interstitial fibrosis and tubular atrophy (IFTA) and vascular injury are frequent histologic features of lupus nephritis renal biopsies, but their clinical correlates and prognostic value are not well understood. This cohort study investigated demographic, clinical and laboratory characteristics, and outcomes, associated with IFTA and vascular injury in lupus nephritis.
METHODS
Reports of all renal biopsies performed at an academic medical center (1990-2017) with WHO/ISN/RPS Class II-V lupus nephritis were reviewed. Demographics, clinical variables and labs at biopsy, treatment, and date of death were collected. Additional data from the U.S. Renal Data System (USRDS) provided dates of ESRD and death after ESRD. Multivariable regression analyses identified demographic and clinical factors associated with each histologic finding. Cumulative incidence functions and multivariable Cox proportional hazard models estimated the risk of progression to ESRD and death.
RESULTS
Within 202 initial biopsies, IFTA was associated with the patient's SLICC/ACR damage index (without renal domain) and serum creatinine, and vascular injury was associated with serum creatinine in multivariable models. In Cox regression models adjusting for age, sex, race, serum creatinine, calendar year, and biopsy class, moderate/severe IFTA was associated with elevated ESRD (HR 5.18, 95% CI 2.53, 10.59) and death (HR 4.19, 95%CI 1.27, 13.81). After adjustment for age, sex and race, moderate/severe vascular injury was associated with ESRD (HR 2.13, 95% CI 1.21, 3.75) and but this relationship was not significant after adjustment for serum creatinine and calendar year.
CONCLUSIONS
IFTA is a strong predictor of ESRD and death, even in proliferative nephritis, and a risk factor for poor outcomes independent of class. Vascular injury is a strong predictor of prognosis, but not independent of serum creatinine and class. The prognostic value of these lesions calls for consideration when determining treatment for lupus nephritis.
背景
间质纤维化和肾小管萎缩（IFTA）和血管损伤是狼疮肾炎肾活检的常见组织学特征，但它们的临床相关性和预后价值尚不清楚。本队列研究调查了与狼疮肾炎 IFTA 和血管损伤相关的人口统计学、临床和实验室特征以及结局。
方法
回顾了 1990 年至 2017 年在一家学术医疗中心进行的所有经世界卫生组织/国际肾脏病学会/肾脏病理学会（WHO/ISN/RPS）II-V 级狼疮肾炎肾活检报告。收集了活检时的人口统计学、临床变量和实验室检查、治疗以及死亡日期。来自美国肾脏数据系统（USRDS）的其他数据提供了终末期肾病（ESRD）后的死亡日期。多变量回归分析确定了与每种组织学发现相关的人口统计学和临床因素。累积发生率函数和多变量 Cox 比例风险模型估计了进展为 ESRD 和死亡的风险。
结果
在 202 例初始活检中，IFTA 与患者的 SLICC/ACR 损伤指数（无肾脏域）和血清肌酐相关，血管损伤与多变量模型中的血清肌酐相关。在调整年龄、性别、种族、血清肌酐、日历年份和活检分级的 Cox 回归模型中，中重度 IFTA 与 ESRD（HR 5.18，95%CI 2.53，10.59）和死亡（HR 4.19，95%CI 1.27，13.81）的风险增加相关。在调整年龄、性别和种族后，中重度血管损伤与 ESRD（HR 2.13，95%CI 1.21，3.75）相关，但在调整血清肌酐和日历年后，这种关系不显著。
结论
IFTA 是 ESRD 和死亡的强有力预测因子，即使在增生性肾炎中也是如此，并且是独立于分级的不良结局的危险因素。血管损伤是预后的强有力预测因子，但与血清肌酐和分级无关。这些病变的预后价值在确定狼疮肾炎的治疗方案时需要考虑。
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