Clinicopathological Characteristics Of Idiopathic Membranous Nephropathy Combined With Focal Segmental Glomerulosclerosis

Objective: It is common to see idiopathic membranous nephropathy(IMN)combined with focal segmental glomerulosclerosis(FSGS).However,the clinical and pathological significance of FSGS in IMN still remains controversial.In this study,we divided FSGS into glomerular tip lesion(GTL)and other types of FSGS,and analyzed their impact on the clinicopathological characteristics and prognosis of membranous nephropathy.Methods: We use statistical methods to retrospectively analyze the clinical and pathological data,and the remission outcome after one-year follow-up of 146 patients diagnosed as IMN,who were admitted in Department of Nephrology of our hospital from December 2016 to March 2019.We divided these patients into three groups according to whether they had FSGS change and types: IMN with no FSGS lesion,(IMN group),IMN combined with GTL(IMN+GTL group),and IMN combined with non-GTL FSGS(IMN+other FSGS group),and then compared the clinicopathological characteristics and clinical outcomes after one year among these three groups.Results: 1.Among 146 IMN patients,the ratio of male to female was 101: 45,the average age at diagnosis was 49±12 years,and the average onset time was 1.0(0.6–4.0)months.There were 81.5% of the patients manifested as nephrotic syndrome.The average serum albumin was 23.6(20–27.3)g/L,and the average 24-hour urinary protein quantitation was 6.46(4.00–8.91)g.IMN group,IMN+GTL group and IMN+other FSGS group accounted for 59.6%,17.1% and 23.3% respectively.2.Compared with patients in IMN group,IMN+other FSGS group showed higher systolic blood pressure and diastolic blood pressure,higher serum cholesterol levels,and lower serum Ig G level(P<0.05).The above levels in the IMN+GTL group were between the other two groups,while there was no statistical significance.At the same time,IMN+other FSGS group and IMN+GTL group showed lower serum albumin levels and more severe proteinuria compared with patients in IMN group(P<0.05),especially the former.3.In terms of renal pathology,IMN+GTL group patients showed a high proportion on severe renal tubular atrophy,interstitial fibrosis,vascular intimal fibrosis,while IMN+other FSGS group showed the highest(P<0.05).Although there was no statistical significance on hyaline degeneration and pathological stage,a higher proportion of patients in the MN+other FSGS group with severe hyaline change and were in the advanced stage of pathology.4.As for the outcome of treatment after one year,the remission rate in IMN+other FSGS group was worse than in both IMN and IMN+GTL groups.The IMN+other FSGS group also performed a lower remission rate in the circumstances of immunosuppressive therapy,serum anti-PLA2 R antibodies positive,high serum anti-PLA2 R antibodies titers,and intermediate-risk proteinuria.5.Multivariate logistic analysis showed that higher serum anti-PLA2 R antibodies and non-GTL FSGS were independent risk factors for the primary outcome.Conclusion: IMN patients with FSGS lesion are likely to present more severe clinical manifestations and pathological changes,and the outcome of treatment in Non-GTL FSGS patients was worse after one year.Non-GTL FSGS is an independent risk factor of the prognosis after one year in IMN patients.