The predictive value and response to immunosuppressive therapy of IgA nephropathy patients with crescents in a large retrospective Chinese cohort.

Background: The prognostic value and response to immunosuppressive therapy (IST) of patients with crescents in the different backgrounds of pathological presentations in immunoglobulin A nephropathy (IgAN) is unclear. Methods: A total of 1262 IgAN patients were enrolled. Crescents (C, 0/1/2), fibrinoid necrosis (FN, 0/1) and endocapillary hypercellularity (E, 0/1) were integrated into different degrees of glomerular activity (0-4 points): mild (0), moderate (1-2) and severe (≥3). The effect of IST on patients with different glomerular activity scores and chronic tubular and interstitial lesions (T, 0/1/2) were analysed using Cox regression analysis. The kidney outcome was defined as an estimated glomerular filtration rate decrease ≥30% or end-stage kidney disease. Results: C2 was an independent risk factor for kidney outcomes {overall cohort: hazard ratio [HR] 1.85 [95% confidence interval (CI) 1.03-3.31], P = .040; T0 patients: HR 6.52 [95% CI 2.92-14.54], P < .001; reference to C0} in those without IST, while the HR decreased to 0.83 (95% CI 0.54-1.27; P = .396) in the overall cohort and 2.39 (95% CI 1.00-5.67; P = .049) in T0 patients with IST. For patients with severe glomerular activity, IST decreased the risk of kidney outcomes by 70% in the overall cohort [HR 0.30 (95% CI 0.12-0.74), P = .009; reference to those without IST] and 86% in T0 patients [HR 0.14 (95% CI 0.04-0.54), P = 0.005; reference to those without IST]. Conclusions: IST could reduce the risk for kidney outcomes in IgAN patients with C2 and T0 lesions together, as well as in those with crescents and at least one other active lesion, including FN and E1 lesions.

The effect of immunosuppressive therapy in patients with fibrinoid necrosis lesions in a large cohort of patients with IgA nephropathy.

BACKGROUND: Fibrinoid necrosis is considered one of the active pathological lesions in IgA nephropathy. Whether patients with IgA nephropathy with fibrinoid necrosis lesions benefit from immunosuppressive therapy in terms of long-term outcomes remains uncertain. This study aimed to evaluate the response to immunosuppressive therapy in patients with fibrinoid necrosis lesions in a large cohort of patients with IgA nephropathy. METHODS: A total of 1325 patients with kidney biopsy-proven IgA nephropathy from 1994 to 2016 were recruited from the Peking University First Hospital IgA Nephropathy Database. The clinicopathological characteristics of patients with fibrinoid necrosis lesions and the effect of immunosuppressive therapy on patients with fibrinoid necrosis lesions alone or in those with fibrinoid necrosis together with crescents or endocapillary hypercellularity lesions were analyzed. RESULTS: In total, 107/1325 (8.1%) patients showed fibrinoid necrosis lesions, and 92/107 (86.0%) of these patients showed fibrinoid necrosis associated either with cellular/fibrocellular crescents or endocapillary hypercellularity lesions. The presence of fibrinoid necrosis together with crescents or endocapillary hypercellularity was an independent risk factor for the kidney composite endpoint (HR, 2.11; 95% CI, 1.16-3.84; P = 0.02) in patients without immunosuppression, while for those receiving immunosuppressive therapy, kidney outcome was improved (HR, 0.80; 95% CI, 0.46-1.39; P = 0.42). However, the predictive value of fibrinoid necrosis lesions alone did not change significantly between patients with and without immunosuppressive therapy. CONCLUSIONS: The presence of fibrinoid necrosis with crescents or endocapillary hypercellularity lesions together, but not fibrinoid necrosis lesions alone, was a pathological indicator of patients who may benefit from immunosuppressive therapy.

Mapping regional differences in payment for ecosystem service policies to inform integrated management: Case study of the Yangtze River Economic Belt.

State and local governments consider payment for ecosystem services (PES) a valuable tool for watershed protection. However, regional differences in PES policies, which significantly influence province-scale cooperation, have been seldom documented. The interrelationships among these policies directly affect overall PES development in the Yangtze River Economic Belt (YREB). Textual analysis was used to categorize the content of PES policies in 11 provinces from 2004 to 2018. Then, we assessed these PES policies with four indicators (i.e., policy intensity, interdepartmental coordination, diversity, and duration). Finally, we analyzed the impact factors of these regional differences. The results showed that the number of PES policies increased yearly, reaching a peak in 2017. Provinces in the upper reaches had the highest policy-intensity score (7.38), followed by downstream provinces (6.39) and provinces in the middle reaches (4.52). Regarding interdepartmental coordination, the downstream areas exhibited the most interdepartment interaction (27.92%), followed by the upstream areas (20.76%) and the middle areas (19.18%). Diversity in the middle reaches was the highest (scored 4.3) while the upstream area exhibited the lowest diversity value (3.25). Downstream provinces issued PES policies the earliest, with a duration 5.52 years, followed by the upstream provinces (4.68) and middle provinces (4.28). Policy intensity was significantly correlated with fixed-asset investment, solid-waste generation, and population. The results suggest that PES in the YREB needs to be strengthened by enhancing policy consistency. In this regard, identifying regional differences in PES policies can help improve the coordination of PES policies for the whole YREB.