The Crescentic Implication Of Renal Outcomes In Proliferative Lupus Nephritis

Background Besides the classification for lupus nephritis,2003ISN/NPS recommended explicit pathological reports including the percentage of glomeruli with crescents and severe active lesions, which are notorious for their refractory to therapy and related poor outcomes. However crescents per se are of various stages.Aim To figure out the association between crescents and renal outcomes, further crescentic implications of therapeutic choices, this study analyzed clinicopathological features and prognosis of crescents of various types and proportions in proliferative lupus nephritis.Methods 231 patients with biopsy proven proliferative lupus nephritis were divided into four groups:59 patients were in none crescent group(NC),59 patients exclusively with segmental crescents formation were in segmental crescent group(SC),patients with circumferential crescents were categorized into two groups according to the crescentic ratio,<25%(C1)and >25%(C2) respectively. Their baseline laboratory tests, histopathological manifestations, responses to drugs and long-term outcomes were compared.Results At baseline, SC presented the highest frequency of positive serum anti-dsDNA antibody and relatively lower serum leukocyte count and complement levels. Immunofluorescence was more intense in SC, especially C1q which was significantly stronger than that in any other group. Patients of C2 had more severe renal manifestations including higher prevalence of rapidly progressive syndrome and nephrotic syndrome, higher serum creatinine and heavier proteinuria at baseline,whereas with less serological activity except lower hemoglobin level. In addition tubulointerstitial lesions(e.g.tubular atrophy, interstitial infiltration), fibrinoid necrosis and mesangial proliferation were more severe in C2. However immunofluorescence intensity was weaker. In multivariate Cox hazard analysis of pathology, higher proportions of cellular crescents (HR=1.044), cellular-fibrinoid crescents (HR=1.125) and glomerular sclerosis (HR=1.037) were correlated with treatment failure. Meanwhile, cellular crescents (HR=1.040), cellular-fibrinoid crescents (HR=1.085) and severe tubular atrophy (HR=5.348) were confirmed as independent risk factors for doubling of serum creatinine.Conclusion Segmental crescents indicate the active deterioration of lupus nephritis both serologically and pathologically. Therefore patients with segmental crescents should receive appropriate intense therapy and will definitely benefit for long term. Cellular crescents and cellular fibrinoid crescents are independent hazard factors for no remission and the incident doubling creatinine. Moreover the percentage of cellular fibrinoid crescents has higher HR than that of cellular crescents from both short and long term perspectives.