Correlation Analysis Of Clinical Features,ISKDC Classification,the Semiquantitative Classification And Prognosis Of Henoch-Sch?nlein Purpura Nephritis In Children

Background: Henoch-Sch?nlein purpura nephritis(HSPN)is the most common secondary glomerulonephritis in Chinese children,most of whom have a good prognosis,but some of them still progress to chronic kidney disease(CKD)or end-stage renal disease(ESRD),so it is necessary to evaluate the patient’s condition and prognosis by clinical feature and renal biopsy pathology early.International Study of Kidney Disease in Children(ISKDC)classification for HSPN has been shown to be limited in predicting the prognosis.The modified semiquantitative classification(SQC)is a new pathological classification proposed in recent years,and its prognostic value of outcomes in HSPN still needs to be further clarified.Objective:1.To explore the relationship between clinical and pathological features and the prognosis of children with HSPN;2.To explore the relationship between SQC indexes and clinical manifestation,traditional pathological classification;3.To compare the efficacy between SQC and ISKDC classification in prognosis prediction,in order to find a more accurate method;4.To explore the value of SQC indexes in predicting short-term and long-term prognosis,so as to find a more sensitive node of prognostic evaluation.Methods: We performed a retrospective review of 249 biopsy-proven patients with HSPN admitted to Children’s Hospital of Chongqing Medical University between December 2011 and December 2017.In addition to the ISKDC classification,renal biopsy specimens were also re-evaluated by the SQC.Results:1.The patients with a poor prognosis had severer clinical manifestation(P = 0.028),significantly higher level of systolic blood pressure(SBP)(P = 0.022),blood urea nitrogen(BUN)(P = 0.007),serum creatinine(Scr)(P = 0.001),Cystatin-C(Cys-C)(P = 0.002),24 h urinary protein(24hUP)(P = 0.015)and lower level of albumin(Alb)(P = 0.015),estimated glomerular filtration rate(eGFR)(P = 0.001).2.Prognosis of HSPN was intimately related to the histological findings.In traditional pathological classifications,the higher the ISKDC classification(P = 0.002)and tubulointerstitial injury grade(P <0.001),the worse the prognosis.In the SQC system,the poor outcomes were significantly related with higher activity index(P <0.001),chronicity index(P <0.001),tubulointerstitial index(P <0.001),glomerular index(P <0.001)and total biopsy score(P <0.001).3.In the SQC system,activity index and chronicity index were positively correlated with clinical manifestation,ISKDC classification,tubulointerstitial injury grade,and 24 hUP.Activity index was negatively correlated with eGFR.Among them,the correlation between activity index and clinical manifestation was stronger than that between chronicity index and clinical manifestation(Z = 2.589,P = 0.009),and the correlation between chronicity index and total biopsy score was stronger than that between activity index and total biopsy score(Z =-7.541,P <0.001).4.Receiver operating characteristic(ROC)analysis for outcomes at the end of the follow-up and histological findings shown the area under the curve(AUC)of the total biopsy score was the largest,0.910(P <0.001,95% CI: 0.844-0.975).The difference in AUC between the total biopsy SQC score and ISKDC classification was 0.12(P = 0.001,95% CI: 0.0485-0.192).Shown by the ROC analysis of the poor outcomes at the 1-year,3-year,5-year follow-up and the total biopsy SQC score,when patients with a total biopsy score of ≥10,they had a higher risk of an adverse outcome.5.Multivariate stepwise Logistic regression analysis showed that eGFR(OR 0.985,95% CI: 0.972-0.997,P = 0.015)and the total biopsy SQC score(OR 1.562,95% CI: 1.279-1.906,P <0.001)were the two most discriminant factors of a poor outcome.Conclusion: Our study suggests that both severe clinical features and advanced biopsy findings are associated with adverse prognosis in children with HSPN.SQC indexes have a clear correlation with clinical and pathological findings of HSPN in children.Activity index is more closely related to the severity of clinical manifestation,and chronicity index is a better indicator of prognosis.SQC is more sensitive and accurate than ISKDC classification in predicting the prognosis of HSPN.The total biopsy SQC score has the strongest predictive efficiency,with the same predictive value in the short-term and long-term prognosis of HSPN in children.When patients with a total biopsy score of ≥10,they have a higher risk of an adverse outcome.