Objective To investigate the clinico-pathological features and renal outcomes of primary IgA nephropathy (IgAN) with glomerular IgM deposition. Methods Primary IgAN diagnosed with biopsy from January 2006 to December 2011 were recruited. Patients were divided into groups according to IgM deposition (Group A) and without IgM deposition (Group B). In addition, Group A was subdivided into two groups based on the position of IgM deposits as the mesangium (Group A1) and both mesangium and capillary wall (Group A2). Renal outcomes were defined as end stage renal disease (ESRD) and/or the doubling of baseline serum creatinine. Clinico-pathological features were retrospectively compared. Kaplan-Meier was conducted for renal outcomes, and Cox regression model was used to analyze the prognostic value of IgM deposition and the position of IgM deposition in the progression of nephropathy in IgAN patients. Results 939 patients were enrolled with 422 (44.9%) having IgM deposition (Group A). Of the 422 patients, 382 patients were divided as Group A1, whereas 40 patients were noted as Group A2. Compared to Group B, hemoglobin, serum protein, albumin and serum IgG levels in group A were significantly lower, and the cholesterol and serum IgM levels were significantly higher (all P＜0.05). There was no significant difference in serum creatinine, estimated glomerular filtration rate (eGFR), urinary protein, blood pressure and uric acid between group A and B. In terms of pathological manifestations, patients in Group A exhibited more severe histological lesions including glomerular sclerosis, S1, M1 and interstitial inflammatory cell infiltration (all P＜0.05). Immunofluorescence showed that the proportion of IgG, C1q and Fg deposition in group A was significantly higher than that in group B (all P＜0.05). By Kaplan-Meier, cumulative renal survival rate has no significant difference between Group A and B (Log-rank test χ2=0.019, P=0.891). Univariate and multivariable Cox regression analysis showed that IgM deposition had no significant effect on the renal progression in IgAN patients. Subgroup analysis showed that patients in Group A2 exhibited higher urine protein, creatinine and blood pressure, and lower eGFR and serum albumin, also had worse histological lesions including M1, E1 and T1-2 of Oxford classification (all P＜0.05), Immunofluorescence showed that the proportion of IgG, C1q and Fg deposition in group A2 was significantly higher than that in group A1 (all P＜0.05). By Kaplan-Meier, renal survival rates calculated from outcomes were lower in Group A2 (Log-rank test χ2=18.207, P＜0.001). In addition, IgM deposited both in the mesangium and capillary wall was a risk factor for renal progression of IgAN patients with IgM deposition by a univariate Cox hazards regression mode and multivariable-adjusted Cox models (HR=3.621, 95%CI 1.924-6.814, P＜0.001; HR=2.309, 95%CI 1.176-4.533, P=0.015 respectively). Conclusions The IgAN patients with IgM deposition relatively had more severe clinico-pathological changes, especially those with IgM deposited both in the mesangium and capillary wall. In this study, IgM deposition was not found to be an independent risk factor for the prognosis of kidney in IgAN patients. However, IgM deposited both in the mesangium and capillary wall was an independent risk factor for renal prognosis in IgAN patients with IgM deposition.

Objective To investigate the factors affecting the efficacy of leflunomide combined with medium/low dose corticosteroids in the treatment of progressive IgA nephropathy (IgAN). Methods Clinical and pathological parameters were collected retrospectively in patients of primary IgAN with proteinuria＞1.0 g/24 h and chronic kidney disease (CKD) stage 1-3 treated with leflunomide combined with medium/low dose corticosteroids in Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University from Jan 2005 to Dec 2010. According to the treatment effects, patients were divided into complete remission group and non-complete remission group. The biochemical and pathological indexes of the two groups were compared. Results A total of 42 patients were included. The remission rates at 3, 6, 9 and 12 months were 62%, 64%, 67% and 74%, respectively. Seventeen (40.5%) and fourteen (33.3%) patients achieved complete and partial remission after one-year treatment, and the remission rate remained stable within one year after withdrawal of drugs. The 24-hour proteinuria was 1.50 (0.67, 2.66) g, which was significantly reduced compared with the baseline 2.44 (1.36, 3.74) g (P＜0.01). The decrease rate was 31.3%. There was a slight decrease in proteinuria within one year after withdrawal of drugs. Estimated glomerular filtration rate (eGFR) remained stable during the treatment and a year of follow-up. No serious adverse event was observed during the follow-up period. Among 31 responder patients, 6(19.4%) patients relapsed. Logistic multivariate regression analysis suggested that the degree of renal interstitial inflammatory infiltration was an independent predictor of complete remission with one-year treatment of leflunomide combined with medium / low dose corticosteroids (HR=0.067, 95%CI 0.008-0.535, P=0.011). Conclusions IgAN treated with leflunomide and medium/low dose corticosteroids can achieve remission in early stage, and the remission rate remains stable after withdrawal of drugs. It is a safe option for the treatment of IgAN. Renal interstitial inflammatory infiltration is an independent predictor of complete remission.

Objective To observe the clinical, pathological features and prognosis of IgA nephropathy in children with crescent formation. Methods A total of 38 cases of children with IgA nephropathy diagnosed by renal biopsy at Qilu Hospital of Shandong University were retrospectively analyzed. According to whether there were crescent formation, they were divided into crescents formation group (crescent formation≥10%, n=18) and control group consisting of children with complete clinical data and matching age, gender and course of disease (no crescent formation, n=20). The clinical, pathological features and prognosis of the two groups were compared. Results Fourteen cases (77.78%) of crescents formation group were associated with nausea hematuria, and 12 cases (66.67%) had hypertension, 8 patients in control group (40%) had gross hematuria, and 6 cases (30%) had high blood pressure. The differences were statistically significant (P＜0.05). In crescents formation group, Alb and eGFR were significantly lower than those of control group. 24 h urine protein and Scr were significantly higher than those of control group and there were significant statistically differences between two groups (P＜0.05). Nephropathological changes in crescent formation group were mainly in grade Ⅱ and grade Ⅲ and were usually combined with tubular interstitial damages. In addition to IgA immunoglobulin deposition, they often accompanied by IgG and IgM immunoglobulin deposition. In control group, nephropathological changes were mainly in grade Ⅰ and grade Ⅱand tubular interstitial damages were rare. IgA was the main form of deposition in control group. After 12 weeks steroid treatment and (or) immunosuppressive therapy, urinary protein turned negative in 7 cases in crescent formation group, 24 h urinary protein level declined by half than before in 7 cases and no obvious change in 4 cases. In control group, urinary protein turned negative in 12 cases, 6 cases showed a more than 50% decline in urinary protein level and 2 cases had no obvious change. During the 1-3 years of follow-up, renal function of 14 cases and 19 cases was normal in the crescent formation group and control group respectively, serum creatinine of 3 cases and 1 case increased mildly in the crescent formation group and control group respectively, 1 case needed dialysis treatment in the crescent formation group and the one in the control group who had slightly increasement of Scr did not reach the standard of dialysis treatment. Conclusions The clinical and pathological manifestations of children with IgA nephropathy with crescent formation are more severe and more likely to manifest renal insufficiency, suggesting that crescent formation is one of the indicators of poor prognosis.

Objective To explore the clinicopathological features and outcomes of IgA nephropathy patients with different proportions of crescents. Methods A total of 270 patients who were diagnosed as IgA nephropathy by renal biopsies from January 2010 to December 2015 in the First Affiliated Hospital of Shenzhen University were enrolled. All patients were divided into 3 groups according to the optimal cutoff level of crescents proportion in the Receiver Operating Characteristic Curve (ROC) as follows: 0%, ＜14%; ≥14%. The endpoint was defined as the doubling of baseline serum creatinine (Scr) and/or end-stage renal disease (ESRD). Kaplan-Meier curve and Cox regression model were used to analyze the renal survival among three groups. Results One hundred and four patients (38.5%) without any crescents; 84 patients (31.1%) with crescents proportion＜14% and 82 patients (31.4%) with crescents proportion ≥14%. Patients with crescents proportion ≥14% group were older and had higher level of systolic blood pressure and diastolic blood pressure, 24-hour urine protein and serum uric acid level; more patients treated with RAS blocker, glucocorticoid and immunotherapy, but lower eGFR, hemoglobin and serum albumin level than those with crescents proportion＜14%. Compared with those without crescents and crescent proportion＜14%, patients with crescent proportion ≥ 14% also had higher proportion of global glomerulosclerosis, more endocapillary hypercellularity and severe tubulointerstitial lesions, higher degree of IgA and C3 depositions in renal. 24-hour proteinuria, serum uric acid level, low hemoglobin level, endocapillary hypercellularity and renal C3 depositions were risk factors for crescents formation. Patients were followed-up for a median of (31.7±21.0) months, and Kaplan-Meier analysis revealed that renal survival rate was significantly lower in patients with crescents proportion ≥14% compared with other groups (P=0.001). But there was no significant difference between no crescent group and crescents proportion＜14% group. However, multivariate Cox analysis showed no significant difference between crescents proportion and renal survival. Conclusion Crescents proportion is associated with higher risk of renal function and renal progression.

Objective To investigate the efficacy of leflunomide combined with prednisone in the induction therapy of proliferative lupus nephritis (LN). Methods A prospective, multicenter, randomized controlled clinical trial was conducted in patients with biopsy-proved proliferative lupus nephritis recruited from 15 renal centers from 2013 to 2015. Patients were randomized to two groups. Oral leflunomide or intravenous cyclophosphamide was given to patients in each group. Both groups received a tapering course of oral prednisone therapy. All patients were followed up for 24 weeks. The blood biochemistry, urine index, clinical curative effect and adverse reaction were recorded and analyzed statistically. Results A total of 100 patients were enrolled in this clinical trial, including 48 patients in leflunomide group and 52 patients in cyclophosphamide group. After 24 weeks, the overall response rate was 79% (95%CI 67%-90%) in the leflunomide group and 69% (95%CI 56%-82%) in the cyclophosphamide group. 23% (95%CI 11%-35%) of patients in leflunomide group showed complete remission compared with 27% (95%CI 24%-30%) in cyclophosphamide group (P=0.35). The levels of 24-hr urine protein excretion, SLEDAI and anti-dsDNA antibody titers were decreased in patients treated with leflunomide group after 24-weeks treatment. And the levels of serum albumin and complement 3 after treatment were significantly higher compared with these before treatment. There was also no significant difference in changes of 24-hr urine protein excretion, SLEDAI score, anti-dsDNA antibody titers, serum albumin and complement C3 levels after treatment between two groups. Incidence of adverse events did not differ between the leflunomide and cyclophosphamide group. Conclusions Leflunomide combined with prednisone showed same efficacy compared with cyclophosphamide as induction therapy for lupus nephritis. Leflunomide might be an useful medicine in the induction therapy of lupus nephritis.

Objective To investigate the risk factors of all-cause mortality in diabetic patients on peritoneal dialysis (PD). Methods As a single-center retrospective cohort study, all incident PD patients who were catheterized at the First Affiliated Hospital of Nanchang University between November 1, 2005 and February 28, 2017 were included. Patients were divided into diabetes mellitus group (DM group) and non-diabetes mellitus group (NDM group). Outcomes were analyzed by Kaplan-Meier method. Multivariate Cox proportional hazards models were utilized to assess the risk factors of all-cause mortality. Results A total of 977 patients were enrolled. Compared with NDM group, patients in DM group were older (47.5±14.4 vs 59.3±11.3, P＜0.01), had more cardiovascular disease (CVD) (7.5% vs 20.3%, P＜0.01), higher levels of serum hemoglobin (78.2±17.2 vs 82.3±14.6 g/L, P＜0.01) , and lower levels of serum albumin (36.1±5.0 vs 32.7±5.6 g/L, P＜0.01). The one-, three- and five-year patient survival rates of DM and NDM group were 89.7%, 56.0%, 31.9% and 94.7%, 81.3%, 67.4%, respectively.Survival rate was significantly lower in DM group than in NDM group ( χ2=63.51, P＜0.01). Stratified analysis showed that DM group had significant lower survival rate than NDM group in patients younger than 70 years old ( χ2= 73.35, P＜0.01), while survival rate was similar between the two groups patients older than 70 years old ( χ2= 0.003, P=0.96). Multivariate Cox proportional hazards model analysis showed that DM (HR: 1.74, 95%CI: 1.27-2.38, P＜0.01), age (HR: 1.05, 95%CI: 1.04-1.06, P＜0.01), leukocyte (HR: 1.06, 95%CI: 1.00-1.12, P=0.04) and triglyceride (HR: 1.19, 95%CI: 1.07-1.32, P＜0.01) were all independent risk factors for all-cause mortality of PD patients. However, age (HR: 1.05, 95%CI: 1.04-1.07, P＜0.01) and alkaline phosphatase (HR: 1.01, 95%CI: 1.00-1.01, P=0.02) were independent risk factors for all-cause mortality of diabetic patients. Conclusions Long-term survival rate was lower in diabetic PD patients than in non-diabetic PD patients. DM, age, leukocyte and triglyceride were independent risk factors of mortality in PD patients. Age and alkaline phosphatase were independent risk factors of mortality in diabetic patients.

Objective To investigate the roles of A kinase anchoring protein1(AKAP1)in high-glucose induced mitochondrial fission in podocytes. Methods Conditionally immortalized human podocytes were cultured in serum-free medium for 24 hours, and then exposed to different glucose concentration conditions in different time periods. The protein expressions of AKAP1 were observed by immunofluorescence, and AKAP1, dynamin related protein1 (Drp1) and phospho Ser 637-Drp1 (p-Drp1) were analyzed by Western blotting. AKAP1 siRNA was transfected to block AKAP1 expression.Podocytes were then divided into normal control group (5 mmol/L glucose), hypertonic group (30 mmol/L mannitol+5 mmol/L glucose), high glucose group (35 mmol/L glucose), and high glucose+AKAP1 siRNA group. Mitochondrial morphological changes were assessed by mitotracker red staining. Podocyte apoptosis was assessed by flow cytometry. Results Compared with normal group, high-glucose induced more podocytes apoptosis (P＜0.05), more mitochondrial fission with decreased aspect ratio and form factor (all P＜0.05). Upregulated AKAP1 protein level, and increased ratio of p-Drp1/Drp1 (all P＜0.05) in time and concentration dependent manners were also observed. Compared with high glucose group, transfection of AKAP1 siRNA showed less apoptosis (P＜0.05), less mitochondrial fission with increased aspect ratio and form factor (all P＜0.05), and down-regulated AKAP1 protein level as well as p-Drp1/Drp1 ratio (all P＜0.05). Conclusion High glucose induced mitochondrial fission might be induced through AKAP1-Drp1 pathway.

Objective To investigate the expression of connective tissue growth factor (CTGF) and heat shock protein 47 (HSP47) in peritoneum fibrosis rats, and the mechanism of 1,25-dihydroxyvitamin D3 [1,25-(OH)2-VitD3] in inhibiting the peritoneum fibrosis. Methods Adult male Sprague-Dawley rats were randomly divided into 3 groups: control group (n=8), model group (n=8) and 1,25-dihydroxyvitamin D3 group (VitD3, n=8). The model of peritoneum fibrosis rats were induced by daily intraperitoneally injection of 15% chlorhexidine gluconate (CHX) 0.2 ml/d with 0.1% glucose for 4 weeks. Rats in VitD3 group were also treated with 1,25-(OH)2-VitD3 [i.p. 6 ng?(100 g)-1?d-1]. Peritoneal transport function, renal function, peritoneum thickness and serum level of 25 hydroxyvitamin D3 were detected. In vitro, primary cultured peritoneal mesothelial cells were divided into control group, high glucose group (HG, 2.5%), CTGF siRNA intervention group (CTGF siRNA+HG), VitD3 intervention group (VitD3+HG) and combined intervention group (CTGF siRNA+VitD3+HG). Real-time PCR, Western blotting and immunofluorescence were applied to measure the expression of CTGF and HSP47, also ELISA was used to detect the protein level of FN in peritoneum and peritoneal mesothelial cells. Results Compared with control group, the peritoneal ultrafiltration in peritoneum fibrosis rats were significantly decreased (P＜0.05), the absorbance level of peritoneal fibrosis, peritoneum thickness, the rate of dialysate urea nitrogen and blood urea nitrogen (DUN/BUN) and the expressions of CTGF and HSP47 were increased (all P＜0.05). After application of 1,25-dihydroxyvitamin D3, peritoneal fibrosis lesion was significantly improved, the peritoneum thickness, the expressions of CTGF and HSP47 were decreased (all P＜0.05). In vitro, 2.5% high glucose induced-peritoneal mesothelial cells were respectively treated by CTGF siRNA, 1,25-(OH)2-VitD3 and combined interventions, the expression of FN, CTGF and HSP47 was significantly lower than that in high glucose group (all P＜ 0.05). Conclusions The expression of CTGF and HSP47 is significantly increased in peritoneal fibrosis rats. 1,25-(OH)2-VitD3 may ameliorate the progression of peritoneal fibrosis via reducing the expression of CTGF, decreasing the expression of HSP47 and FN.

Objective To investigate the effect of prostaglandin E2 receptor 1 (EP1) on Adriamycin (ADR)-induced glomerular podocytes injury and its possible mechanism. Methods (1) In vivo experiments: 6-8 weeks old male Balb/c mice were randomly divided into four groups: Control group; ADR group; EP1 agonist 17-phenyl PGE2+ADR group; EP1 antagonist SC-19220+ADR group. The mouse model of nephrotic syndrome was induced by injection of ADR (10 mg/kg) into tail vein, and then EP1 agonist (1 μg/g) and antagonist (25 μg/g) were administered respectively. Six weeks later, all mice were sacrificed and urine, blood and kidney tissues were collected. Detecting urine protein, blood chemistry, changes of renal pathology and podocyte-related proteins, electron microscopy changes of podocytes. (2) In vitro experiments: Podocytes were cultured in vitro and divided into different groups: Control group; ADR group (0.2 μmol/L); EP1 agonist (0.1, 1, 10 μmol/L)+ADR (0.2 μmol/L) group; antagonist (0.1, 0.5, 1 μmol/L)+ADR (0.2 μmol/L) group. The proliferation of podocytes was measured by CCK-8. Expression of PGE2 in podocytes was detected by ELISA. Indirect immunofluorescence was used to determine the localization of podocyte-related proteins nephrin, podocin and CD2AP. Expression of nephrin, podocin, CD2AP, COX2 in podocytes was detected by Western blotting and Real-time quantitative PCR. p38 MAPK or phospho-p38 MAPK was measured by Western blotting as well. Flow cytometry was used to detect cell apoptosis. Results (1) In vivo experiments: Compared with control group, obvious proteinuria, blood biochemical changes and renal pathological changes were observed in ADR group, proteinuria, blood biochemical and renal pathological changes were more serious in mice dealt with agonist, while antagonist could reduce ADR-induced injury (all P＜0.05). Results of immunohistochemistry showed that the expression of podocyte-related proteins nephrin, podocin and CD2AP in ADR group were significantly lower than those in control group, and EP1 agonist could further inhibit expression of these proteins, while antagonist could reverse this inhibitory effects (P＜0.05). Electron microscopic results showed that mice in ADR group appeared foot enlargement and fusion, and the agonist group further aggravated the injury, while antagonist intervention could inhibit the injury of podocytes. (2) In vitro experiments: Compared with control group, expression of PGE2 and COX2 were increased; mRNA and protein expression of nephrin, podocin, CD2AP were decreased, p38 MAPK activity and podocytes apoptosis were increased in ADR group (P＜0.05); Agonist could aggravate podocytes damage (P＜0.05), while Antagonist could down-regulate the expression of PGE2 and COX2, promote the expression of nephrin, podocin and CD2AP, and inhibit the activity of p38 MAPK and podocytes apoptosis (P＜0.05). The addition of p38 MAPK inhibitor(10 μmol/L) could reduce the inhibitory effect of EP1 agonist on the expression of podocyte-related proteins nephrin, podocin and CD2AP (P＜0.05). Conclusions EP1 receptor may activate the p38 MAPK signaling pathway to inhibit podocytes-related proteins nephrin, podocin and CD2AP, as well as mediate the ADR induced podocyte injury. Inhibition of EP1 receptor however have a protective effect.