Objective To compare the efficacy and safety of leflunomide (LEF) combined with medium/low dose corticosteroids and full dose of corticosteroids in the treatment of IgA nephropathy. Method Primary IgAN patients diagnosed by renal biopsy with 18-65 years old and eGFR≥30 ml?min-1?(1.73 m2)-1 and proteinuria＞0.5 g/24 h were enrolled in a prospective controlled clinical study. They were randomly divided into leflunomide combined with medium /low dose corticosteroids (LEF group) and corticosteroids alone (steroid group). The primary outcomes were (1) end stage renal disease or dialysis (2) 50% increase in serum creatinine above the baseline. Secondary outcome was the remission of proteinuria. Results Ninety patients completed the follow-up. The 24-hour proteinuria at baseline were 2.00(1.10, 2.88) g and 1.87(1.13，3.08) g in LEF group and steroid group respectively. Compared with baseline, it was significantly decreased in both groups at 6 months [0.30(0.11, 0.93) g, 0.30(0.14, 1.33) g] and 12 months [0.30(0.09, 0.82) g, 0.32(0.14, 0.66) g], (P＜0.05). Estimated glomerular filtration rate (eGFR) at baseline, 6 months and 12 months were (80.39±28.56), (87.12±28.70) and (88.20±30.26) ml?min-1?(1.73 m2)-1. It was decreased in steroid group (P＜0.05), while no significant difference was detected in LEF group[baseline (87.63±27.35), 6 months (86.91±32.45), 12 months (90.06±30.00) ml?min-1?(1.73 m2)-1, P＞0.05]. At 6 and 12 months, there was no significant difference in terms of 24-hour proteinuria, serum creatinine and eGFR (CKD-EPI) between groups (P＞0.05). There was no statistically significant difference in adverse events between groups during the treatment (9/40 cases in LEF group and 11/50 cases in steroid group, P＞0.05). The average follow-up was 79 months, and there was no difference in the renal prognosis between the two groups. Multivariate Cox regression analysis revealed that serum creatinine at baseline and renal interstitial inflammatory cell infiltration predicted the risk of the progress of IgA nephropathy. Conclusion Leflunomide plus medium/low dose corticosteroids has a similar effect as full dose of corticosteroids in IgA nephropathy and does not increase the risk for adverse events during the treatment.

Objective To investigate the clinical and pathological characteristics of IgA nephropathy (IgAN) in association with active tubular interstitial lesions. Methods 148 patients who were diagnosed as IgAN by renal biopsy and admitted to Zhejiang Provincial People's Hospital from March 2014 to December 2014 were enrolled. They were divided into IgAN with active tubular interstitial lesions group (IgAN-ATIL group, 23 patients) and IgAN without active tubular interstitial lesions group (control group, 125 patients). Clinical and pathological characteristics were retrospectively analyzed. Multivariate logistic regression analysis was used to analyze the influence factors. Results The prevalence of ATIL in 148 IgAN patients was 15.5%. IgAN-ATIL group showed an older average age and more higher proportion of medication history (antibiotics, diuretics, nonsteroidal anti-inflammatory drugs, etc) than those in control group. There were significant differences in Alb, eGFR, Scr, BUN, 24-hour urinary protein quantity, urinary NGAL and urinary RBC count between two groups (P＜0.05, respectively). A moderate of tubulointerstitial lesions of IgAN-ATIL group was shown, while the control group was mainly mild lesions. Multivariate logistic regression analysis showed that age, medication history and the urinary NGAL level were independent risk factors of IgAN-ATIL. Conclusions IgAN patients with active tubular interstitial lesions had more severe clinical manifestations and chronic interstitial lesions. The age, medication history (antibiotics, diuretics, nonsteroidal anti-inflammatory drugs, etc) and the urinary NGAL level were independent risk factors of IgAN-ATIL.

Objective To analyze the prognosis and risk factors for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) patients on maintaining dialysis. Methods AAV patients on maintaining peritoneal dialysis (PD) or hemodialysis (HD) in First Affiliated Hospital Zhejiang University from June 2007 to June 2015 were included, and were followed up until death, kidney transplant, changed dialysis modalities or January 31, 2016. Patients were divided into PD group and HD group for comparison. Their survival rates and risk factors were analyzed by Kaplan-Meier analysis and COX regression model respectively. Results A total of 123 cases were chosen, with a median duration of dialysis for 854 (388, 1573) days, and with 88 cases (71.5%) on HD and 35 cases (28.5%) on PD. Fifty-two patients (42.3%) were more than 65 years old. At the median follow-up time of 36 months, 39 patients (31.7%) died. The main causes of death were cardiovascular events (30.8%) and infection (23.1%). COX regression analysis showed that patients older than 65 years old (HR=3.289, P=0.001), with cardiovascular disease (HR=3.241, P=0.003) and interstitial pneumonia (HR=2.173, P=0.048) at the dialysis onset were independent risk factors affecting survival. Conclusions Factors including age (older than 65 years), pre-dialysis cardiovascular disease and interstitial pneumonia were independent risk factors affecting survival of AAV patients on maintaining dialysis, then infections and cardiovascular events were the main causes of death.

Objective To compare the complications and outcomes of urgent-start peritoneal dialysis (PD) and hemodialysis (HD) in end-stage renal disease (ESRD) patients, and explore the safety and effectiveness of PD which was as an urgent-start dialysis modality in ESRD patients. Methods All patients for urgent-start dialysis, who initiated dialysis without a long-term dialysis access or had the long-term dialysis access under 30 days in Renji Hospital from January 1st 2013 to December 31st 2014, were enrolled. According to the dialysis modalities, patients were divided into PD group and HD group. Participants were followed up until death, transferred to other centers, lost of follow up or January 1st 2016. Dialysis-related complications within 30 days of implantation, complications of reimplantation and the occurrence of bacteremia between two groups were compared, and their survival rates were tested by Kaplan-Meier curves. Results Among 178 patients in this study, there were 96 (53.9%) patients in PD group and 82 (46.1%) patients in HD group. Compared with those of HD group, patients of PD group presented more cardiovascular disease [21(21.9%) vs 8(9.8%), P=0.029], higher serum potassium [(4.5±0.8) mmol/L vs (4.3±0.8) mmol/L, P=0.038], but less heart failure (NYHA Ⅲ-Ⅳ) [26(30.2%) vs 40 (48.8%), P=0.014], lower brain natriuretic peptide (BNP) [328.5 (129.5, 776.8) ng/L vs 503.5(206.0, 1430.0) ng/L, P=0.008], higher hemoglobin [(81.5±17.7) g/L vs (75.3±22.5) g/L, P=0.039], higher serum albumin (33.5±5.7) g/L vs (31.3±6.7) g/L, P=0.022] and higher serum pre-albumin (304.5±78.0) mg/L vs (257.0±86.1) mg/L, P＜0.001]. PD group presented less dialysis-related complications [5(5.2%) vs 20(24.4%), P＜0.001], less dialysis-related complications requiring reimplantation [1(1.0%) vs 20(24.4%), P＜0.001] and less bacteraemia [3(3.1%) vs 11(13.4%), P=0.011]. The 3-, 6-and 12-month patient survival rates of PD and HD group were 97.9% vs 98.4%, 97.9% vs 98.4%, and 92.1% vs 93.0% respectively, and no significant difference was found (Log-rank=0.004, P=0.947). Conclusions Patients with urgent-start PD have less complications within 30 days of implantation and occurrence of bacteremia than patients with urgent-start HD, and the same survival rates. PD may be a feasible and safe urgent-start dialysis modality for ESRD patients.

Objective To analyze the impac factors of serum N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with renal failure in non-dialysis phase, and to determine the cut-off point of as a diagnostic values in these patients with heart failure (HF). Methods Cross-sectional study was applied. Clinical data of 145 patients (37 cases of CKD4, 89 cases of CKD5, and 19 cases of acute renal injury (AKI) with renal failure in non-dialysis phase were collected. Comparison between groups and lineal regression analysis were utilized to investigate the impact factors of NT-proBNP, and the receiver operating characteristic curve (ROC curve) to select a better cut-off point of diagnosis in these patients with HF. Results (1) Compared with patients without HF, patients with HF had significantly higher edema, cardiac troponin I, serum phosphorus concentration, and left atrial diameter (LA), while ALB and left ventricular ejection fraction (LVEF) were decreased (P＜0.05). (2) The NT-proBNP was divided into 4 groups with four points: First groups of 36 cases, NT-proBNP 1 -862 ng/L, second groups 37 cases, 866-2670 ng/L, third groups 37 cases, 2790-20 000 ng/L, fourth groups 35 cases, 20 900-35 000 ng/L. With the increase of NT-proBNP levels, the occurrence of AKI and CKD4 decreased gradually while the occurrence of CKD and edema were significantly increased (P＜0.01). Systolic blood pressure, troponin I, uric acid, serum phosphorus, parathyroid hormone, 24 hours urine protein, LA, interventricular septum thickness (IVS), left ventricular posterior wall thickness (LVPW) level gradually increased. Hb, ALB, calcium, CO2, eGFR, LVEF significantly decreased (P＜0.01). The serum NT-proBNP of patients with HF was significantly higher than that of patients without HF (19 150 ng/L vs 1530 ng/L, P＜0.01). The serum NT-proBNP of patients with edema was significantly higher than that in patients without edema (5460 ng/L vs 1630 ng/L, P＜0.01). (3) Single factor linear regression analysis indicated that higher NT-proBNP was positive correlated with HF, edema, cardiac troponin I, uric acid, serum phosphorus, LA, IVS and LVPW (P＜0.05), while negative correlated with Hb, eGFR, ALB, serum calcium, CO2, LVEF (P＜0.05), and not correlated with eGFR, uric acid, serum calcium (P＞0.05). (4) The best cut-off point of NT-proBNP predicting HF in patients with renal failure in non-dialysis phase was 3805 ng/L, AUC=0.848, 95%CI 0.786-0.910. Sensitivity was 82.4%, specificity 74.5%, positive predictive value 62.1%, negative predictive value 87.3%, positive likelihood ratio 3.2, negative likelihood ratio 0.24. Conclusions The level of NT-proBNP＞20 000 ng/L is mainly found in end-stage renal disease patients with HF. HF is a main factor for the increase of NT-proBNP in patients with renal failure in non-dialysis phase. High phosphorus viremia, anemia, and hypoalbuminemia are closely related to NT-proBNP. Therefore NT-proBNP predicting HF should take into account the effects of these confounding factors in these patients.

Objective Through selecting abnormal DNA methylation of children steroid resistance nephrotic syndrome and bioinformatics analysis to find the pathogenesis of steroid resistance nephrotic syndrome and provide new targets for therapy. Methods We use illumine 450K methylation chip to detected blood gene DNA methylation of 9 cases of children primary nephrotic syndrome. 9 cases were divided into 2 groups: G1 is the group of steroid sensitive nephritic syndrome, a total of 4 cases; G2 is the group of steroid resistance nephrotic syndrome, a total of 5 cases. Selected the abnormal DNA methylation in children steroid resistant nephritic syndrome, clarified the function of those genes through using functional annotation of gene GO, enrichment analysis and KEGG pathway analysis, conducted the preliminary analysis on children with steroid resistant nephrotic syndrome of gene methylation. Results Compared with the control group, G2 has a number of genes that were extensively methylated. According to the results of bioinformatics analysis, the abnormal DNA methylation in G2 is the components of the various kinds of organelles and cell membrane. They also regulated the polymerization and composition of cytoskeleton and actin, as well as involved in the process of metabolism of many amino acids and drug. Conclusions The abnormal DNA methylation in the group 2 have extensive role, offering possibility of clinical prediction and provided potential therapeutic targets.

Objective To explore the effects of L-type calcium channel (LTCC) α1C and β3 subunits on that magnesium inhibited thoracic aortic calcification induced by β-glycerophosphate (β-GP). Methods Vascular smooth muscle cells (VSMCs) and aortic rings from rat aortic were cultured, then divided into control group, high phosphorus group (10 mmol/L β-GP), magnesium group (10 mmol/L β-GP+3 mmol/L MgSO4) and 2-APB (an inhibitor of magnesium transporter) group (10 mmol/L β-GP+3 mmol/L MgSO4+0.1 mmol/L 2-APB). Calcium deposition of VSMCs and aortic rings were respectively measured by alizarin red staining and Von Kossa staining, meanwhile the quantification of their calcium was tested by OCPC. The mRNA expressions of Runx2, LTCC α1C and β3 in VSMCs were detected by RT-PCR, and their protein expressions were detected by Western blotting. Intracellular calcium ion of VSMCs was tested by fluorescence probe and alkaline phosphatase (ALP) activity was measured by ELISA. The Runx2 expression of aortic rings was detected by immunohistochemistry. Results After VSMCs stimulated for 7 days, calcium, ALP, mRNA and protein expressions of LTCCα1C, LTCCβ3 and Runx2, and intracellular calcium ion in high phosphorus group were higher than those in control group (all P＜0.05). Moreover, calcium, ALP, mRNA and protein expressions of LTCCα1C, LTCCβ3 and Runx2, and intracellular calcium ion were decreased in magnesium group as compared with those in high phosphorus group (all P＜0.05). In aortic rings, magnesium group had lower calcium and protein expression of Runx2 than high phosphorus group. No statistical difference between 2-APB group and high phosphorus group was observed in above indexes (all P＞0.05). Conclusion Magnesium may down-regulate expressions of LTCC α1C and β3 subunit, prevent calcium influx and then inhibit osteogenic differentiation so as to reduce β-glycerophosphate-induced VSMCs calcification.

Objective To investigate the role of hypoxia-inducible factor-2α (HIF-2α) in the expression of tight junction proteins and permeability alterations in rat glomerular endothelial cells (rGENCs) under hypoxia condition. Methods The expressions of the HIF-2α and tight junction proteins such as occludin and ZO-1 of rGENCs were examined after exposed to 5% oxygen at different treatment time periods (0 h, 12 h, 24 h and 48 h). Then lentiviral transfection was used to knock down HIF-2α expression in rGENCs. The cells were split into four groups, including i) control group where rGENCs were cultured under normal oxygen conditions, ii) hypoxia group, iii) negative control group where rGENCs were infected with a negative vector, iv) HIF-2α lentivirus transfection group. Group ii, iii and iv were kept in hypoxic chamber (5% O2, 5% CO2 and 90% N2) for 24 h. The expressions of occludin, ZO-1 and HIF-2α were assessed by Western blotting. The permeability of rGENCs was measured using trans-epithelium electrical resistant (TEER) by Millicell? ERS voltohmmeter. Results With the elongation of hypoxia time, the expression of HIF-2α was increased gradually, while the occludin expression was decreased, there was statistically significance difference in each group (all P＜0.01). The expression of ZO-1 also decreased gradually under hypoxia circumstance, but no statistically significant was found between 24 h and 48 h groups (all P＞0.05). And a dramatic decrease in TEER of hypoxia cells was detected as compare with control cells (P＜0.01). After knockdown of HIF-2α expression, both expressions of occludin and ZO-1 were increased significantly compared with hypoxia cells (P＜0.01), and TEER elevated at the same time (P＜0.01). Above indexes had no statistical difference between hypoxia cells and negative control cells (all P＞0.05). Conclusion Hypoxia may promote HIF-2α expression, which could increase the permeability of rGENCs by reducing the expression of occludin and ZO-1.

Objective To observe the changes of STAT3 signaling transduction pathway and autophagy activity in human glomerular mesangial cells cultured in high glucose, as well as the effect of STAT3 on autophagy, exploring whether SAT3 further influence extracellular matrix proteins type IV collagen secretion through the regulation of autophagy. Methods Culture human renal mesangial cells under different conditions, STAT3 pathway was inhibited with specific blocking agent S3I-201 and siRNA respectively. The experiment was divided into: (1) Control group: normal glucose concentration; (2) High glucose group: divided into 12 h, 24 h, 48 h, 72 h incubation group. (3) High glucose+S3I-201 group: pretreated cells with 30 μmol/L S3I-201 (Selleck S1155) for 1 h, then incubation with high glucose for another 24 hours. (4) High glucose+STAT3-siRNA group: siRNA transfection firstly, then incubation with high glucose for 24 hours. (5) High glucose+S3I-201+3-MA group: pretreated cells with 2 mmol/L 3-MA (Selleck S2767) and 30 μmol/L S3I-201 for 1 h, then incubation with high glucose for another 24 hours. Western blot was employed to detect the protein of STAT3, p-STAT3 and autophagy related protein LC3, p62 expressions. The changes of autophagosome quantity was observed with transmission electron microscope. The extracellular matrix protein collagen IV expression was measured with ELISA. Results Compared with the control group, glomerular mesangial cells cultured with high glucose for 24h, the expressions of STAT3 and p-STAT3 increased (P＜0.01), while the expression of autophagy related proteins LC3II/LC3I decreased. The expression of p62 increased and the number of autophagosome reduced under transmission electron microscope, which all indicated the decrease of autophagy activity (P＜0.05). Blocking STAT3 signaling pathway with S3I-201 and STAT3-siRNA respectively, compared with high glucose group, LC3II/LC3I was up-regulated and p62 was down-regulated, and the number of autophagosome was increased significantly, which all indicated the increase of autophagy activity (P＜0.05). Extracellular matrix proteins collagen IV expression of cells cultured with high glucose was higher than the control group (P＜0.05), and the application of S3I-201 blocking STAT3 pathway caused type IV collagen expression to decrease (P＜0.05). The application of the autophagy inhibitor 3-MA could convert the result and lead to an increase of type IV collagen expression (P＜0.01). Conclusions High glucose could active STAT3 signaling pathway of human renal mesangial cell and increase STAT3, p-STAT3 expression. High glucose could inhibit autophagy activity of human renal mesangial cells. Inhibition of STAT3 pathway activation may reduce the inhibitory effect of high glucose on autophagy of human renal mesangial cells. High glucose leads to an increase of type IV collagen secretion of human glomerular mesangial cells. The activation of STAT3 pathway may increase type IV collagen secretion through negative regulation of autophagy, which eventually leads to diabetic nephropathy.