The predictive value of crescents in the disease progression of lupus nephritis based on the 2018 International Society of Nephrology/Renal Pathology Society Revision System: a large cohort study from China

This study analyzed the associations of different crescents’ fraction and clinical features in a Chinese lupus nephritis cohort based on the 2018 revision of ISN/RPS classification system.
A total of 288 lupus nephritis patients with complete clinicopathological data and well follow-up was enrolled. The fraction of glomeruli with cellular or fibrocellular crescents based on the new system was reevaluated. The association between crescents fractions and the outcomes were further analyzed.
The median follow-up period was 76.5 months. Cellular or fibrocellular crescents were present in 146 (50.7%) of the total individuals. The percentage of crescents were significantly associated with severe clinical renal injury indices and other renal pathological parameter. According to the survival receiver operating characteristic (survival ROC) curve, the optimal cutoff level of cellular or fibrocellular crescents for predicting the composite events was 7.39%. By multivariable Cox hazard analysis, the presence of crescents was predictive of survival from the composite events with a hazard ratio [HR] of 2.5 (95% CI 1.190–5.431; p = .02). Furthermore, when we used absent, present in less than 7.39% of glomeruli, and present in greater than or equal to 7.39% of glomeruli as cutoffs in all the patients, a gradation appeared, with adjusted HRs of 2.9 (95% CI 1.326–6.313; p = .008) for crescents in greater than or equal to 7.39% of glomeruli, in reference to no crescents.
We proposed that the crescents were not uncommon and had important clinical significance in lupus nephritis. The cutoff point of crescents as prognosticator might be nearly 7.39%.

本研究基于2018年修订的国际肾脏病学会/肾脏病理学会（ISN/RPS）狼疮肾炎分类系统，分析了中国狼疮肾炎队列中不同新月体比例与临床特征的关联。
本研究共纳入288例具备完整临床病理资料且随访情况良好的狼疮肾炎患者，重新评估了基于新版分类系统的伴细胞性或纤维细胞性新月体的肾小球占比，并进一步分析了新月体比例与患者预后的关联。
患者的中位随访时长为76.5个月。总计146例（占比50.7%）患者存在细胞性或纤维细胞性新月体。新月体占比与严重临床肾损伤指标及其他肾脏病理参数显著相关。根据生存受试者工作特征（survival ROC）曲线，用于预测复合终点事件的细胞性/纤维细胞性新月体最佳截断值为7.39%。经多变量Cox风险分析显示，新月体的存在可预测复合终点事件的生存结局，风险比（HR）为2.5（95%置信区间CI：1.190~5.431；p=0.02）。此外，若以无新月体、肾小球新月体占比<7.39%、肾小球新月体占比≥7.39%作为截断值对所有患者进行分组，则可见显著梯度效应：以无新月体组为参照，肾小球新月体占比≥7.39%组的校正后HR为2.9（95%CI：1.326~6.313；p=0.008）。
本研究提示，新月体在狼疮肾炎中并不少见，且具有重要临床意义；以新月体占比作为预后标志物的最佳截断值约为7.39%。