IgA肾病牛津分类在中国成人及儿童患者中的多中心验证研究
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摘要
研究I：1155例中国汉族成人IgA肾病患者的长期预后及其临床危险因素分析
目的：阐明我国汉族成人IgA肾病(IgAN)患者的长期预后及其相关危险因素,并明确IgAN患者尿蛋白的控制目标值。
方法：利用南京军区南京总医院全军肾脏病研究所IgAN随访登记数据库,分析1989年至2005年期间经肾活检确诊IgAN患者的随访资料。利用Kaplan-Meier法计算本组患者的累积肾脏生存率,并利用COX回归模型分析相关危险因素。
结果：共1126例患者纳入本研究,中位随访时间为5.5年,88例患者(7.8%)在随访期间进入ESRD,144例(12.4%)患者在随访中达到终点事件(eGFR下降50%或进入ESRD)。患者肾活检后10年、15年、20年累积肾脏生存率分别为：85%、74%、67%。多因素COX回归分析结果表明,肾活检时尿蛋白定量>1.0g/d (HR3.3, P<0.001)血压>140/90mmHg(HR1.9, P<0.001)、eGFR<60ml/min per1.73m2(HR2.6,P<0.001)、以及高尿酸血症(血尿酸>420umol/L,HR1.8, P=0.002)是肾脏预后的独立危险因素。随访中患者尿蛋白、血压及镜下血尿程度也与其肾脏长期预后独立相关,其中以随访中平均尿蛋白定量(Time-average proteinuria, TA-P)最为重要。TA-P预测患者进入终点事件的ROC曲线下面积高达0.9,最佳截点约为1.0g/d(敏感性81%,特异性85%)。校正其他影响因素后,TA-P>1.0g/d者进入终点事件的风险较<1.0g/d者增加9.4倍(P<0.001),较<0.5g/d者增加46.5倍(P<0.001),而且TA-P介于0.5-1.0g/d者进入终点事件的风险仍较<0.5g/d者增加9.1倍(P<0.001)
结论：本研究结果表明我国成人IgAN患者10年、20年肾脏累积生存率分别为85%、67%。肾活检时的4项临床指标：尿蛋白、肾功能受损程度、血压状态、高尿酸血症,以及随访中的3项临床指标：尿蛋白、血压、镜下血尿程度是患者进展至ESRD的独立危险因素。随访过程中蛋白尿持续不缓解是患者进入ESRD最主要的危险因素。中国成人IgAN患者的尿蛋白基本控制目标值为<1.0g/d,理想控制目标值为<0.5g/d。
研究Ⅱ：IgA肾病牛津分类在中国成人患者中的多中心验证研究
背景：2009年国际IgAN协作组(International IgA nephropathy network)和肾脏病理学会(Renal Pathology Society)公布了IgAN牛津分类系统,该分类系统提出对病人预后有影响的四项指标制定了量化标准,制定了对肾组织病变进行详细评分的评分表。然而IgAN牛津分类系统仍然存在一些缺陷,推广之前还需接受不同人群的验证性研究。
目的：评价IgAN牛津分类系统在中国汉族成年IgAN患者人群的可重复性和适用性。
方法：由全国18个临床肾脏病中心共同参与。患者的纳入排除标准与原Oxford研究相似,两位病理学专家严格按照IgAN牛津分类标准完成每例患者的评分表,评价IgAN牛津分类的可重复性及其与肾脏临床预后间的相关性。
结果：共有来自18个肾脏病临床中心的1026例IgAN患者纳入本研究,其中系膜积分>0.5(M1)者占43%,伴肾小球节段硬化或粘连(S1)者高达83%,中度肾小管萎缩/间质纤维化(T1)者占24%,中重度度肾小管萎缩/间质纤维化(T2)者占3.3%,伴毛细血管内增殖性病变(E1)者仅占11%。高达48%的患者存在新月体病变,但新月体病变肾小球超过25%者仅占2.4%,患者新月体病变肾小球占所有肾小球总数的比率的中位数位仅8%。117例(15%)患者见袢坏死性病变。本组患者随访时间的中位数为53月(四分位间距为36-67月),15.5%的患者(159例)在随访中出现联合终点事件。回归分析结果显示,肾小球系膜增殖性病变(M)和肾小管萎缩/间质纤维化(T)可用于预测中国汉族IgAN患者的肾脏预后,但毛细血管内增殖性病变(E)、肾小球节段硬化或粘连(S)、新月体、袢坏死与IgAN患者肾脏预后无显著的相关性。
结论：IgAN牛津分类在中国汉族IgAN患者中的可重复性较佳。IgAN牛津分类中肾小球系膜增殖性病变(M)和肾小管萎缩/间质纤维化(T)与中国汉族IgAN患者的肾脏预后独立相关,但毛细血管内增殖性病变(E)、肾小球节段硬化或粘连(S)、新月体、袢坏死与IgAN患者肾脏预后无显著的相关性。毛细血管内增殖性病变(E)、新月体、袢坏死病变能否用于指导使用免疫抑制剂仍有待相关随机对照试验进一步研究。
研究Ⅲ：IgA肾病牛津分类在中国儿童患者中的多中心验证研究
背景：2009年国际IgAN协作组(International IgA nephropathy network)和肾脏病理学会(Renal Pathology Society)公布了IgA1肾病牛津分类系统,该分类系统提出对病人预后有影响的四项指标制定了量化标准,制定了对肾组织病变进行详细评分的评分表,然而IgAN牛津分类系统仍然存在一些缺陷,推广之前还需接受验证性研究的检验。
目的：评价IgAN牛津分类系统在中国汉族未成年IgAN患者人群的适用性。
方法：由全国7个临床肾脏病中心共同参与。患者的纳入排除标准与原Oxford研究相似,两位病理学专家严格按照IgAN牛津分类标准完成每例患者的评分表。评价IgAN牛津分类与肾脏临床预后间的相关性。
结果：共有来自7个肾脏病临床中心的218例IgAN患儿纳入本研究,其中系膜增殖性积分>0.5者(M1)占45%,伴毛细血管内增殖性病变(E1)者占23%,伴肾小球节段硬化或粘连者(S1)高达62%,中度肾小管萎缩/间质纤维化(T1)者占6%,中重度度肾小管萎缩/间质纤维化者(T2)仅2例(1%)。高达48%的患者存在新月体病变。本组患者随访时间的中位数为56月,12.4%的患者(24例)在随访中出现联合终点事件。结果显示肾小管萎缩/间质纤维化(T)与患者肾脏预后最为密切(HR4.3,P<0.001),而肾小球节段硬化或粘连(S)和系膜增殖性积分(M)在不同的回归模型中结果并不一致。新月体、袢坏死与本组IgAN患者肾脏预后无显著的相关性。
结论：IgAN牛津分类中仅肾小管萎缩/间质纤维化(T)与中国汉族儿童IgAN患者的肾脏预后独立相关。
Part I:Long-term renal survival and related risk factors in patients with IgA nephropathy:Results from a cohort of1155cases in a Chinese adult population
Background We sought to identify the long-term renal survival rate and related risk factors of progression to renal failure in Chinese adult patients with IgA nephropathy(IgAN) and to quantify the effects of proteinuria during the follow-up on outcome in patients with IgAN.
Methods Patients with biopsy-proven primary IgAN in the Nanjing Glomerulonephritis Registry were studied. Renal survival and the relationships between clinical parameters and renal outcomes were assessed.
Results1155patients were enrolled in this study. The10,15, and20-year cumulative renal survival rates, calculated by Kaplan-Meier method, were83%,74%and64%respectively. At the time of biopsy, proteinuria>1.0g/d (HR3.2, P<0.001), eGFR<60 ml/min per1.73m2(HR2.6, P<0.001), hypertension (HR1.9, P<0.001), hypoproteinemia (HR2.0, P<0.001), and hyperuricemia (HR2.1, P<0.001) were the independent risk factors. Multivariate COX analysis showed the time-average proteinuria(TA-P) during follow-up was the most important risk factor of renal failure. Patients with TA-P>1.0g/d were associated with a9.4-fold risk than patients with TA-P<1.0g/d (P<0.001), and46.5-fold risk than those with TA-P<0.5g/d (P<0.001). Moreover, patients who achieved TA-P<0.5g/d benefit much more than those with TA-P between0.5and1.0g/d (HR13.1, P<0.001).
Conclusions36%of Chinese adult patients with IgAN have progressed to End Stage of Renal Disease (ESRD) within20years. Five clinical features--higher proteinuria, hypertension, impaired renal function, hypoproteinemia and hyperuricemia are independent predictors of an unfavorable renal outcome. The basic goal of antiproteinuric therapy for Chinese patients is to lower proteinuria less than1.0g/d, and the optimal goal is to lower proteinuria to less than0.5g/day.
Part II:A Multi-center Application and Evaluation of the Oxford Classification of IgA Nephropathy in Chinese adult patients
Background:The Oxford classification of IgA nephropathy (IgAN) provides a histopathological grading system that is associated with kidney disease outcomes, independent of clinical features. However, the application of the Oxford IgAN classification should be evaluated in larger cohorts and in different ethnic groups.
Methods:Retrospective study. A total of1026adults with IgAN from18renal centers in China were enrolled in this study. The inclusion criteria and statistical analysis were similar to the Oxford study. Predictors:Histologic findings of mesangial hypercellularity score, endocapillary proliferation, segmental sclerosis or adhesion, crescents, necrosis, tubular atrophy/interstitial fibrosis. Clinical features of blood pressure, estimated glomerular filtration rate (eGFR), proteinuria, and treatment modalities. Outcomes:Time to a50%reduction in renal function or ESRD (the combined event); the rate of renal function decline (slope of eGFR); proteinuria during follow-up.
Results:The Chinese cohort had a lower proportion of patients with mesangial hypercellularity (43%) and endocapillary proliferation (11%), a higher proportions of segmental sclerosis or adhesion (83%), and necrosis (15%), and a similar proportion with crescents (48%) and tubular atrophy/interstitial fibrosis (moderate, T1,24%; severe, T2,3.3%) compared with the Oxford cohort. During a median follow-up period of53months (interquartile range36-67months), the mean (SD) rate of eGFR decline was-1.5±10.4ml/min/1.73m2per year, the mean urine protein excretion was0.7g/d (interquartile range0.45-1.2g/d), and15.5%of patients (159cases) reached the combined event. Our study showed that patients with mesangial hypercellularity>0.5were associated with a2.0-fold (95%CI1.5-2.8, P<0.001) risk of the combined event than those patient with mesangial hypercellularity<0.5, patients with tubular atrophy/interstitial fibrosis of25-50%were associated with a3.7-fold (95%CI2.6-5.1, P<0.001) risk of the combined event than those patient with tubular atrophy/interstitial fibrosis<25%, and patients with tubular atrophy/interstitial fibrosis>50%were associated with a15.1-fold (95%CI9.5-24.2, P<0.001) risk of the combined event than those patient with tubular atrophy/interstitial fibrosis<25%. However, endocapillary proliferation, glomerular crescents and necrosis showed no significant prognostic value in the Chinese cohort.
Conclusions:We confirmed the associations of mesangial hypercellularity and tubular atrophy/interstitial fibrosis with kidney disease outcomes.
Part III:Validation of the Oxford Classification of IgA Nephropathy for Pediatric Patients from China
Background:The Oxford classification of IgA nephropathy (IgAN) provides a useful tool for prediction of renal prognosis. However, the application of this classification in children with IgAN needs validation in different patient populations.
Methods. A total of218children with IgAN from7renal centers in China were enrolled. The inclusion criteria was similar to the original Oxford study.
Results. There were98patients (45%) with mesangial proliferation (M1),51patients (23%) with endocapillary proliferation (E1),136patients (62%) with segmental sclerosis/adhesion lesion (S1),13patients (6%) with moderate tubulointerstitial fibrosis (T126-50%of cortex scarred), and only2patients (1%) with severe tubulointerstitial fibrosis (T2,>50%of cortex scarred). During a median follow-up duration of56months,24children (12.4%) developed ESRD or50%decline in renal function. We found that tubular atrophy/interstitial fibrosis (HR4.3, P<0.001) was the most powerful lesion for predicting renal prognosis, while associations between some pathological lesions (mesangial hypercellularity, segmental sclerosis or adhesion) and renal outcome were inconsistent in different models. Moreover, endocapillary proliferation, crescents, and necrosis were not associated with renal prognosis.
Conclusions. We confirmed tubular atrophy/interstitial fibrosis was the only feature independently associated with renal outcomes in Chinese children with IgAN.
目的：阐明我国汉族成人IgA肾病(IgAN)患者的长期预后及其相关危险因素,并明确IgAN患者尿蛋白的控制目标值。
方法：利用南京军区南京总医院全军肾脏病研究所IgAN随访登记数据库,分析1989年至2005年期间经肾活检确诊IgAN患者的随访资料。利用Kaplan-Meier法计算本组患者的累积肾脏生存率,并利用COX回归模型分析相关危险因素。
结果：共1126例患者纳入本研究,中位随访时间为5.5年,88例患者(7.8%)在随访期间进入ESRD,144例(12.4%)患者在随访中达到终点事件(eGFR下降50%或进入ESRD)。患者肾活检后10年、15年、20年累积肾脏生存率分别为：85%、74%、67%。多因素COX回归分析结果表明,肾活检时尿蛋白定量>1.0g/d (HR3.3, P<0.001)血压>140/90mmHg(HR1.9, P<0.001)、eGFR<60ml/min per1.73m2(HR2.6,P<0.001)、以及高尿酸血症(血尿酸>420umol/L,HR1.8, P=0.002)是肾脏预后的独立危险因素。随访中患者尿蛋白、血压及镜下血尿程度也与其肾脏长期预后独立相关,其中以随访中平均尿蛋白定量(Time-average proteinuria, TA-P)最为重要。TA-P预测患者进入终点事件的ROC曲线下面积高达0.9,最佳截点约为1.0g/d(敏感性81%,特异性85%)。校正其他影响因素后,TA-P>1.0g/d者进入终点事件的风险较<1.0g/d者增加9.4倍(P<0.001),较<0.5g/d者增加46.5倍(P<0.001),而且TA-P介于0.5-1.0g/d者进入终点事件的风险仍较<0.5g/d者增加9.1倍(P<0.001)
结论：本研究结果表明我国成人IgAN患者10年、20年肾脏累积生存率分别为85%、67%。肾活检时的4项临床指标：尿蛋白、肾功能受损程度、血压状态、高尿酸血症,以及随访中的3项临床指标：尿蛋白、血压、镜下血尿程度是患者进展至ESRD的独立危险因素。随访过程中蛋白尿持续不缓解是患者进入ESRD最主要的危险因素。中国成人IgAN患者的尿蛋白基本控制目标值为<1.0g/d,理想控制目标值为<0.5g/d。
研究Ⅱ：IgA肾病牛津分类在中国成人患者中的多中心验证研究
背景：2009年国际IgAN协作组(International IgA nephropathy network)和肾脏病理学会(Renal Pathology Society)公布了IgAN牛津分类系统,该分类系统提出对病人预后有影响的四项指标制定了量化标准,制定了对肾组织病变进行详细评分的评分表。然而IgAN牛津分类系统仍然存在一些缺陷,推广之前还需接受不同人群的验证性研究。
目的：评价IgAN牛津分类系统在中国汉族成年IgAN患者人群的可重复性和适用性。
方法：由全国18个临床肾脏病中心共同参与。患者的纳入排除标准与原Oxford研究相似,两位病理学专家严格按照IgAN牛津分类标准完成每例患者的评分表,评价IgAN牛津分类的可重复性及其与肾脏临床预后间的相关性。
结果：共有来自18个肾脏病临床中心的1026例IgAN患者纳入本研究,其中系膜积分>0.5(M1)者占43%,伴肾小球节段硬化或粘连(S1)者高达83%,中度肾小管萎缩/间质纤维化(T1)者占24%,中重度度肾小管萎缩/间质纤维化(T2)者占3.3%,伴毛细血管内增殖性病变(E1)者仅占11%。高达48%的患者存在新月体病变,但新月体病变肾小球超过25%者仅占2.4%,患者新月体病变肾小球占所有肾小球总数的比率的中位数位仅8%。117例(15%)患者见袢坏死性病变。本组患者随访时间的中位数为53月(四分位间距为36-67月),15.5%的患者(159例)在随访中出现联合终点事件。回归分析结果显示,肾小球系膜增殖性病变(M)和肾小管萎缩/间质纤维化(T)可用于预测中国汉族IgAN患者的肾脏预后,但毛细血管内增殖性病变(E)、肾小球节段硬化或粘连(S)、新月体、袢坏死与IgAN患者肾脏预后无显著的相关性。
结论：IgAN牛津分类在中国汉族IgAN患者中的可重复性较佳。IgAN牛津分类中肾小球系膜增殖性病变(M)和肾小管萎缩/间质纤维化(T)与中国汉族IgAN患者的肾脏预后独立相关,但毛细血管内增殖性病变(E)、肾小球节段硬化或粘连(S)、新月体、袢坏死与IgAN患者肾脏预后无显著的相关性。毛细血管内增殖性病变(E)、新月体、袢坏死病变能否用于指导使用免疫抑制剂仍有待相关随机对照试验进一步研究。
研究Ⅲ：IgA肾病牛津分类在中国儿童患者中的多中心验证研究
背景：2009年国际IgAN协作组(International IgA nephropathy network)和肾脏病理学会(Renal Pathology Society)公布了IgA1肾病牛津分类系统,该分类系统提出对病人预后有影响的四项指标制定了量化标准,制定了对肾组织病变进行详细评分的评分表,然而IgAN牛津分类系统仍然存在一些缺陷,推广之前还需接受验证性研究的检验。
目的：评价IgAN牛津分类系统在中国汉族未成年IgAN患者人群的适用性。
方法：由全国7个临床肾脏病中心共同参与。患者的纳入排除标准与原Oxford研究相似,两位病理学专家严格按照IgAN牛津分类标准完成每例患者的评分表。评价IgAN牛津分类与肾脏临床预后间的相关性。
结果：共有来自7个肾脏病临床中心的218例IgAN患儿纳入本研究,其中系膜增殖性积分>0.5者(M1)占45%,伴毛细血管内增殖性病变(E1)者占23%,伴肾小球节段硬化或粘连者(S1)高达62%,中度肾小管萎缩/间质纤维化(T1)者占6%,中重度度肾小管萎缩/间质纤维化者(T2)仅2例(1%)。高达48%的患者存在新月体病变。本组患者随访时间的中位数为56月,12.4%的患者(24例)在随访中出现联合终点事件。结果显示肾小管萎缩/间质纤维化(T)与患者肾脏预后最为密切(HR4.3,P<0.001),而肾小球节段硬化或粘连(S)和系膜增殖性积分(M)在不同的回归模型中结果并不一致。新月体、袢坏死与本组IgAN患者肾脏预后无显著的相关性。
结论：IgAN牛津分类中仅肾小管萎缩/间质纤维化(T)与中国汉族儿童IgAN患者的肾脏预后独立相关。
Part I:Long-term renal survival and related risk factors in patients with IgA nephropathy:Results from a cohort of1155cases in a Chinese adult population
Background We sought to identify the long-term renal survival rate and related risk factors of progression to renal failure in Chinese adult patients with IgA nephropathy(IgAN) and to quantify the effects of proteinuria during the follow-up on outcome in patients with IgAN.
Methods Patients with biopsy-proven primary IgAN in the Nanjing Glomerulonephritis Registry were studied. Renal survival and the relationships between clinical parameters and renal outcomes were assessed.
Results1155patients were enrolled in this study. The10,15, and20-year cumulative renal survival rates, calculated by Kaplan-Meier method, were83%,74%and64%respectively. At the time of biopsy, proteinuria>1.0g/d (HR3.2, P<0.001), eGFR<60 ml/min per1.73m2(HR2.6, P<0.001), hypertension (HR1.9, P<0.001), hypoproteinemia (HR2.0, P<0.001), and hyperuricemia (HR2.1, P<0.001) were the independent risk factors. Multivariate COX analysis showed the time-average proteinuria(TA-P) during follow-up was the most important risk factor of renal failure. Patients with TA-P>1.0g/d were associated with a9.4-fold risk than patients with TA-P<1.0g/d (P<0.001), and46.5-fold risk than those with TA-P<0.5g/d (P<0.001). Moreover, patients who achieved TA-P<0.5g/d benefit much more than those with TA-P between0.5and1.0g/d (HR13.1, P<0.001).
Conclusions36%of Chinese adult patients with IgAN have progressed to End Stage of Renal Disease (ESRD) within20years. Five clinical features--higher proteinuria, hypertension, impaired renal function, hypoproteinemia and hyperuricemia are independent predictors of an unfavorable renal outcome. The basic goal of antiproteinuric therapy for Chinese patients is to lower proteinuria less than1.0g/d, and the optimal goal is to lower proteinuria to less than0.5g/day.
Part II:A Multi-center Application and Evaluation of the Oxford Classification of IgA Nephropathy in Chinese adult patients
Background:The Oxford classification of IgA nephropathy (IgAN) provides a histopathological grading system that is associated with kidney disease outcomes, independent of clinical features. However, the application of the Oxford IgAN classification should be evaluated in larger cohorts and in different ethnic groups.
Methods:Retrospective study. A total of1026adults with IgAN from18renal centers in China were enrolled in this study. The inclusion criteria and statistical analysis were similar to the Oxford study. Predictors:Histologic findings of mesangial hypercellularity score, endocapillary proliferation, segmental sclerosis or adhesion, crescents, necrosis, tubular atrophy/interstitial fibrosis. Clinical features of blood pressure, estimated glomerular filtration rate (eGFR), proteinuria, and treatment modalities. Outcomes:Time to a50%reduction in renal function or ESRD (the combined event); the rate of renal function decline (slope of eGFR); proteinuria during follow-up.
Results:The Chinese cohort had a lower proportion of patients with mesangial hypercellularity (43%) and endocapillary proliferation (11%), a higher proportions of segmental sclerosis or adhesion (83%), and necrosis (15%), and a similar proportion with crescents (48%) and tubular atrophy/interstitial fibrosis (moderate, T1,24%; severe, T2,3.3%) compared with the Oxford cohort. During a median follow-up period of53months (interquartile range36-67months), the mean (SD) rate of eGFR decline was-1.5±10.4ml/min/1.73m2per year, the mean urine protein excretion was0.7g/d (interquartile range0.45-1.2g/d), and15.5%of patients (159cases) reached the combined event. Our study showed that patients with mesangial hypercellularity>0.5were associated with a2.0-fold (95%CI1.5-2.8, P<0.001) risk of the combined event than those patient with mesangial hypercellularity<0.5, patients with tubular atrophy/interstitial fibrosis of25-50%were associated with a3.7-fold (95%CI2.6-5.1, P<0.001) risk of the combined event than those patient with tubular atrophy/interstitial fibrosis<25%, and patients with tubular atrophy/interstitial fibrosis>50%were associated with a15.1-fold (95%CI9.5-24.2, P<0.001) risk of the combined event than those patient with tubular atrophy/interstitial fibrosis<25%. However, endocapillary proliferation, glomerular crescents and necrosis showed no significant prognostic value in the Chinese cohort.
Conclusions:We confirmed the associations of mesangial hypercellularity and tubular atrophy/interstitial fibrosis with kidney disease outcomes.
Part III:Validation of the Oxford Classification of IgA Nephropathy for Pediatric Patients from China
Background:The Oxford classification of IgA nephropathy (IgAN) provides a useful tool for prediction of renal prognosis. However, the application of this classification in children with IgAN needs validation in different patient populations.
Methods. A total of218children with IgAN from7renal centers in China were enrolled. The inclusion criteria was similar to the original Oxford study.
Results. There were98patients (45%) with mesangial proliferation (M1),51patients (23%) with endocapillary proliferation (E1),136patients (62%) with segmental sclerosis/adhesion lesion (S1),13patients (6%) with moderate tubulointerstitial fibrosis (T126-50%of cortex scarred), and only2patients (1%) with severe tubulointerstitial fibrosis (T2,>50%of cortex scarred). During a median follow-up duration of56months,24children (12.4%) developed ESRD or50%decline in renal function. We found that tubular atrophy/interstitial fibrosis (HR4.3, P<0.001) was the most powerful lesion for predicting renal prognosis, while associations between some pathological lesions (mesangial hypercellularity, segmental sclerosis or adhesion) and renal outcome were inconsistent in different models. Moreover, endocapillary proliferation, crescents, and necrosis were not associated with renal prognosis.
Conclusions. We confirmed tubular atrophy/interstitial fibrosis was the only feature independently associated with renal outcomes in Chinese children with IgAN.
引文
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8. 刘志红,黎磊石.IgA肾病的分型治疗.肾脏病与透析肾移植杂志2002；11(1)：2.
9. 张希燃,王庆文,陈惠萍,et al.微小病变样IgA肾病的临床病理特征及激素疗效分析.肾脏病与透析肾移植杂志2011；20(2).
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2. Berger J, Hinglais N. [Intercapillary deposits of IgA-IgG]. J Urol Nephrol (Paris) 1968;74(9):694-5.
3. 刘志红.IgA肾病不是一个均一的疾病：知难行亦难.中华肾脏病杂志2008；24(7)：2.
4. Lai KN. Recent advances in IgA Nephropathy. In:World Scientific; 2008,9-19.
5. D'Amico G. Natural history of idiopathic IgA nephropathy and factors predictive of disease outcome. Semin Nephrol 2004;24(3):179-96.
6. Lv J, Zhang H, Zhou Y, et al. Natural history of immunoglobulin A nephropathy and predictive factors of prognosis:a long-term follow up of 204 cases in China. Nephrology (Carlton) 2008;13(3):242-6.
7. Goto M, Wakai K, Kawamura T, et al. A scoring system to predict renal outcome in IgA nephropathy:a nationwide 10-year prospective cohort study. Nephrol. Dial. Transplant. 2009;24(10):3068-3074.
8. 刘志红,黎磊石.IgA肾病的分型治疗.肾脏病与透析肾移植杂志2002；11(1)：2.
9. 张希燃,王庆文,陈惠萍,et al.微小病变样IgA肾病的临床病理特征及激素疗效分析.肾脏病与透析肾移植杂志2011；20(2).
10. Li PK, Ho KK, Szeto CC, et al. Prognostic indicators of IgA nephropathy in the Chinese-clinical and pathological perspectives. Nephrol Dial Transplant 2002;17(l):64-9.
11. Le W, Liang S, Hu Y, et al. Long-term renal survival and related risk factors in patients with IgA nephropathy:results from a cohort of 1155 cases in a Chinese adult population. Nephrol Dial Transplant 2012;27(4):1479-85.
12. Geddes CC, Rauta V, Gronhagen-Riska C, et al. A tricontinental view of IgA nephropathy. Nephrol Dial Transplant 2003;18(8):1541-8.
13. Koyama A, Igarashi M, Kobayashi M. Natural history and risk factors for immunoglobulin A nephropathy in Japan. Research Group on Progressive Renal Diseases. Am J Kidney Dis 1997;29(4):526-32.
14. Reich HN, Troyanov S, Scholey JW, et al. Remission of proteinuria improves prognosis in IgA nephropathy. Journal of the American Society of Nephrology 2007;18(12):3177-3183.
15. Vuong MT, Hahn-Zoric M, Lundberg S, et al. Association of soluble CD89 levels with disease progression but not susceptibility in IgA nephropathy. Kidney Int 2010;78(12):1281-7.
16. Alamartine E, Sabatier JC, Berthoux FC. Comparison of pathological lesions on repeated renal biopsies in 73 patients with primary IgA glomerulonephritis:value of quantitative scoring and approach to final prognosis. Clin Nephrol 1990;34(2):45-51.
17. Radford MG, Jr., Donadio JV, Jr., Bergstralh EJ, et al. Predicting renal outcome in IgA nephropathy. J Am Soc Nephrol 1997;8(2):199-207.
18. Katafuchi R, Kiyoshi Y, Oh Yy et al. Glomerular score as a prognosticator in IgA nephropathy:its usefulness and limitation. Clin Nephrol 1998;49(1):1-8.
19. Lee SM, Rao VM, Franklin WA, et al. IgA nephropathy:morphologic predictors of progressive renal disease. Hum Pathol 1982;13(4):314-22.
20. Haas M. Histologic subclassification of IgA nephropathy:a clinicopathologic study of 244 cases. Am J Kidney Dis 1997;29(6):829-42.
21. Manno C, Strippoli GF, D'Altri C, et al. A novel simpler histological classification for renal survival in IgA nephropathy:a retrospective study. Am J Kidney Dis 2007;49(6):763-75.
22. Eitner F, Floege J. Glomerular disease:the Oxford classification--predicting progression of IgAN. Nat Rev Nephrol 2009;5(10):557-9.
23. Hill GS, Nochy D, El Karoui K. Comments on the Oxford classification of IgA nephropathy. Kidney Int 2009;76(11):1207.
24. Mubarak M. Nomenclature of the Oxford classification of IgA nephropathy:do we need to be careful? Kidney Int 2010;77(1):74; author reply 74-5.
25. Suzuki H, Kiryluk K, Novak J, et al. The pathophysiology of IgA nephropathy. J Am Soc Nephrol 2011;22(10):1795-803.
26. Barratt J, Feehally J. Primary IgA Nephropathy:new insights into pathogenesis. Seminars in Nephrology 2011;31(4):349-360.
27. Glassock RJ. The pathogenesis of IgA nephropathy. Curr Opin Nephrol Hypertens 2011;20(2):153-60.
28. Barratt J, Smith AC, Molyneux K, et al. Immunopathogenesis of IgAN. Semin Immunopathol 2007;29(4):427-43.
29. Hiki Y. O-linked oligosaccharides of the IgA1 hinge region:roles of its aberrant structure in the occurrence and/or progression of IgA nephropathy. Clin Exp Nephrol 2009;13(5):415-23.
30. Mestecky J, Tomana M, Moldoveanu Z, et al. Role of aberrant glycosylation of IgA1 molecules in the pathogenesis of IgA nephropathy. Kidney & Blood Pressure Research 2008;31(1):29-37.
31. Allen AC, Willis FR, Beattie TJ, et al. Abnormal IgA glycosylation in Henoch-Schonlein purpura restricted to patients with clinical nephritis. Nephrol Dial Transplant 1998;13(4):930-4.
32. Moldoveanu Z, Wyatt RJ, Lee JY, et al. Patients with IgA nephropathy have increased serum galactose-deficient IgA1 levels. Kidney International 2007;71(11):1148-1154.
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