C3 Hypocomplementemia Predicts the Progression of CKD towards End-Stage Kidney Disease in IgA Nephropathy, Irrespective of Histological Evidence of Thrombotic Microangiopathy

Background: IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. IgAN causes end-stage kidney disease (ESKD) in 30-40% of all cases. The activation of the complement system by pathological circulating IgAs, which is often associated with low serum C3 levels (LowC3), seems to play a crucial role. Previous studies have shown an association between histological evidence of TMA, which is the result of alternative complement activation, and poor outcomes. However, it is not known to what extent the decrease in serum C3 levels reflects ongoing TMA injury. Our study aimed at assessing the association between LowC3 and ESKD and whether this association reflects ongoing TMA. Methods: We enrolled all patients with biopsy-proven IgAN and followed-up patients until their last visit, ESKD, or death. Results: Of the 56 patients included in the study, 12 (21%) presented low serum C3 (LowC3) at the time of renal biopsy. TMA was significantly more frequent in the LowC3 group [7/12 (58%) vs. 9/44 (20%), p = 0.02]. After adjusting for potential confounders, LowC3 was strongly associated with an increased hazard of ESKD (hazard ratio [HR]: 5.84 [95%CI: 1.69, 20.15; p = 0.005). The association was not affected by adjusting for TMA. The estimated overall proportion of the relation between C3 and ESKD mediated by TMA was low and not statistically significant. Conclusions: Our study provides evidence that C3 hypocomplementemia is associated with an increased risk of ESKD through mechanisms that are largely independent from TMA.

Borderline rejection: To treat or not to treat?

INTRODUCTION

It is unclear whether kidney transplant recipients with a biopsy diagnosis as a "borderline" acute T-cell mediated rejection (TCMR) requires the treatment with intravenous (iv) steroids pulse plus/minus intensification of the maintenance therapy (TRT) in comparison with the simple clinical follow-up (F-UP).

METHODS

We retrospectively followed a consecutive series of kidney transplant recipients diagnosed with a borderline acute TCMR at biopsy by surveillance or clinical indication for 12 months and compared TRT and F-UP groups. We evaluated trends in renal function by measuring estimated glomerular filtration rate (eGFR) using multiple regression models. Repeated eGFR measures (REML) were adjusted for potential confounding factors for 12 months. The difference in 12-month eGFR values were observed in the TRT vs F-UP groups, type of biopsy, as well as the surveillance vs. clinical outcomes.

RESULTS

Out of 59 included patients, 37% of them were in the TRT group and remaining 63% in the F-UP group. As expected, the TRT group had, at the time of biopsy, lower eGFR value of 39.0 ml/min/m2 [16.5] in comparison to 49.6 [19.6] ml/min/m2 in the F-UP group (P = 0.043), Similarly, the TRT group required more frequent clinical biopsies vs. F-UP group (68% vs. 32%; P = 0.014). However, the TRT group recovered kidney function reaching the eGFR values of the F-UP group at 12 months; the increase being significant only in patients who received indication biopsies (P < 0.001). The estimated adjusted TRT effect on 12-month eGFR change after indication biopsy was improved by +15.8 ml/min/1.73m2 (95%CI: +0.1 to +31.4 ml/min/1.73 m2; P = 0.048 by three-way interaction term) compared to the F-UP group.

CONCLUSION

Our preliminary study supports the indication for the treatment of acute borderline TCMR only in cases with biopsies performed by clinical indication.

Thrombotic microangiopathy due to primary antiphospholipid syndrome: successful treatment with eculizumab

Antiphospholipid syndrome nephropathy includes a variety of histological lesions, including thrombotic microangiopathy, which is not included among the diagnostic criteria of antiphospholipid syndrome. Whereas in secondary antiphospholipid syndrome, e.g. to systemic lupus erythematosus, there is emerging evidence of a benefit from complement blockade with eculizumab, optimal treatment of primary antiphospholipid syndrome-associated thrombotic microangiopathy is currently unknown. We report the case of a 36-year-old male patient with primary antiphospholipid syndrome-associated thrombotic microangiopathy, presenting with a clinical picture of atypical hemolytic-uremic syndrome with frequent relapses, treated with eculizumab (four 900 mg weekly doses followed by 1200 mg fortnightly infusions) leading to resolution of hemolysis, long-term remission and partial kidney function recovery (peak serum creatinine 3.8 mg/dL, decreased and stabilized around 2.5 mg/dL) over a follow up period of over 2 years.

Persistent Isolated C3 Hypocomplementemia as a Strong Predictor of End-Stage Kidney Disease in Lupus Nephritis

Introduction

Proliferative lupus nephritis (LN) progresses to end-stage kidney disease (ESKD) in roughly 10% of the cases despite treatment. Other than achieving <0.8 g/24h proteinuria at 12 months after treatment, early biomarkers predicting ESKD or death are lacking. Recent studies encompassing not only LN have highlighted the central role of the alternative complement pathway (ACP), with or without histological evidence of thrombotic microangiopathy (TMA), as a key promotor of renal death.

Methods

We assessed whether persistent isolated C3 hypocomplementemia (PI-LowC3), that is not accompanied by C4 hypocomplementemia, 6 months after kidney biopsy, is associated with an increased risk of death or ESKD in proliferative LN.

Results

We retrospectively followed-up 197 patients with proliferative LN (51 with PI-LowC3) for a median of 4.5 years (interquartile-range: 1.9-9.0), 11 of whom died and 22 reached ESKD. After adjusting for age, gender, ethnicity, hypertension, mycophenolate, or cyclophosphamide use, PI-LowC3 was associated with a hazard ratio [HR] of the composite outcome ESKD or death of 2.46 (95% confidence interval [CI]: 1.22-4.99, P = 0.012). These results were confirmed even after controlling for time-varying estimated glomerular filtration rate (eGFR) measurements in joint longitudinal-survival multiple regression models. After accounting for the competing risk of death, PI-LowC3 patients showed a strikingly increased risk of ESKD (adjusted HR 3.41, 95% CI: 1.31-8.88, P = 0.012).

Conclusion

Our findings support the use of PI-LowC3 as a low-cost readily available biomarker, allowing clinicians to modify treatment strategies early in the course of disease and offering a rationale for complement blockade trials in this particularly at-risk subgroup of LN patients.

The Role of Rituximab in Primary Focal Segmental Glomerular Sclerosis of the Adult

Introduction

Primary focal segmental glomerular sclerosis (FSGS) is a rare, likely immune-mediated disease. Rituximab (RTX) may play a role in management, although data in adults are scanty.

Methods

We collected cases of RTX-treated primary FSGS within the Italian Society of Nephrology Immunopathology Working Group and explored response rate (24-hour proteinuria <3.5 g and <50% compared with baseline, stable estimated glomerular filtration rate).

Results

A total of 31 patients were followed for at least 12 months; further follow-up (median 17 months, interquartile range [IQR] 15–33.5) was available for 11. At first RTX administration, median creatinine and 24-hour proteinuria were 1.17 mg/dl (IQR 0.83–1.62) and 5.2 g (IQR 3.3–8.81), respectively. Response rate at 3, 6, and 12 months was 39%, 52%, and 42%, respectively. In the first 12 months, creatinine level remained stable whereas proteinuria and serum albumin level improved, with an increase in the proportion of patients tapering other immunosuppressants. There were 6 patients who were retreated with RTX within 12 months, either for proteinuria increase or refractory disease; only the 2 responders to the first RTX course experienced a further response. At univariate analysis, 6-month response was more frequent in steroid-dependent patients (odds ratio [OR] 7.7 [95% CI 1.16–52.17]) and those with proteinuria <5 g/24 h (OR 8.25 [1.45–46.86]). During long-term follow-up, 4 of 5 responders at 12 months maintained a sustained response, either without further immunosuppression (2 of 4) or with pre-emptive RTX (2 of 4); 1 relapsed and responded to RTX retreatment.

Conclusion

RTX may be an option in primary FSGS, especially in steroid-dependent patients, with 24-hour proteinuria <5 g and previously responders to RTX. Optimal long-term management for responders is unclear, with some patients experiencing sustained remission and others requiring RTX retreatment, either preemptive or after rising proteinuria.

A Comparative Analysis of Nutritional Assessment Using Global Leadership Initiative on Malnutrition Versus Subjective Global Assessment and Malnutrition Inflammation Score in Maintenance Hemodialysis Patients

OBJECTIVE

Malnutrition is a prevalent condition in maintenance hemodialysis (MHD) patients. This study aimed to evaluate the performance of the recently developed GLIM (Global Leadership Initiative on Malnutrition) in MHD by assessing the agreement, accuracy, sensitivity, specificity, and survival prediction of GLIM when compared to 7-point subjective global assessment (7p-SGA) and malnutrition inflammation score (MIS).

DESIGN AND METHODS

We investigated 2 cohorts: MHD_ltaly (121 adults from Italy; 67 ± 16 years, 65% men, body mass index 25 ± 5 kg/m²) and MHD_Brazil (169 elderly [age > 60 years] from Brazil; 71 ± 7 years, 66% men, body mass index 25 ± 4 kg/m²), followed for all-cause mortality for median 40 and 17 months, respectively. We applied the 2-step approach from GLIM: (1) screening and (2) confirming malnutrition by phenotypic and etiologic criteria. For 7p-SGA and MIS, a score ≤5 and ≥8, respectively, defined malnutrition.

RESULTS

Malnutrition was present in 38.8% by GLIM, 25.6% by 7p-SGA, and 29.7% by MIS in the MHD_Italy cohort, and in 47.9% by GLIM, 59.8% by 7p-SGA, and 49.7% by MIS in the MHD_Brazil cohort. Cohen's kappa coefficient (κ) showed only "fair" agreement between GLIM and SGA (MHD_Italy: κ = 0.26, P = .003; MHD_Brazil: κ = 0.22, P = .003) and between GLIM and MIS (MHD_Italy: κ = 0.33, P < .001; MHD_Brazil: κ = 0.25, P = .001). Cox regression analysis showed that all 3 methods were able to predict mortality in crude analysis; however in the adjusted model, the association seemed more consistent and stronger in magnitude for 7p-SGA and MIS.

CONCLUSION

In MHD patients, GLIM showed low agreement, sensitivity, and accuracy in identifying malnourished subjects by either 7p-SGA or MIS. Considering the specific wasting characteristics that predominate in MHD, the well-established 7p-SGA and MIS methods may be more useful in this clinical setting.

Ultrasound for Non-invasive Assessment and Monitoring of Quadriceps Muscle Thickness in Critically Ill Patients With Acute Kidney Injury

Background and aims: Critically ill patients with acute kidney injury (AKI) undergo major muscle wasting in the first few days of ICU stay. An important concern in this clinical setting is the lack of adequate tools for routine bedside evaluation of the skeletal muscle mass, both for the determination of nutritional status at admission, and for monitoring. In this regard, the present study aims to ascertain if ultrasound (US) is able to detect changes in quadriceps muscle thickness of critically ill patients with acute kidney injury (AKI) over short periods of time. Methods: This is a prospective observational study with a follow-up at 5 days. All adult patients with AKI hospitalized at the Renal ICU of the Parma University Hospital over 12 months, with a hospital stay before ICU admission no longer than 72 h, and with a planned ICU stay of at least 5 days, were eligible for the study. An experienced investigator assessed quadriceps rectus femoris and vastus intermedius thickness (QRFT and QVIT) at baseline and after 5 days of ICU stay. Results: We enrolled 30 patients with 74 ± 11 years of age and APACHE II score of 22 ± 5. Muscle thickness decreased by 15 ± 13% within the first 5 days of ICU stay (P < 0.001 for all sites as compared to ICU admission). Patients with more severe muscle loss had lower probability of being discharged home (OR: 0.04, 95%CI: 0.00-0.74; P = 0.031). Conclusions: In critically ill patients with AKI, bedside muscle US identifies patients with accelerated muscle wasting.

Integrated strategies to prevent intradialytic hypotension: research protocol of the DialHypot study, a prospective randomised clinical trial in hypotension-prone haemodialysis patients

INTRODUCTION

In patients on maintenance haemodialysis (HD), intradialytic hypotension (IDH) is a clinical problem that nephrologists and dialysis nurses face daily in their clinical routine. Despite the technological advances in the field of HD, the incidence of hypotensive events occurring during a standard dialytic treatment is still very high. Frequently recurring hypotensive episodes during HD sessions expose patients not only to severe immediate complications but also to a higher mortality risk in the medium term. Various strategies aimed at preventing IDH are currently available, but there is lack of conclusive data on more integrated approaches combining different interventions.

METHODS AND ANALYSIS

This is a prospective, randomised, open-label, crossover trial (each subject will be used as his/her own control) that will be performed in two distinct phases, each of which is divided into several subphases. In the first phase, 27 HD sessions for each patient will be used, and will be aimed at the validation of a new ultrafiltration (UF) profile, designed with an ascending/descending shape, and a standard dialysate sodium concentration. In the second phase, 33 HD sessions for each patient will be used and will be aimed at evaluating the combination of different UF and sodium profiling strategies through individualised dialysate sodium concentration.

ETHICS AND DISSEMINATION

The trial protocol has been reviewed and approved by the local Institutional Ethics Committee (Comitato Etico AVEN, prot. 43391 22.10.19). The results of the trial will be presented at local and international conferences and submitted for publication to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03949088).

[Eculizumab as rescue therapy for lupus nephritis-related thrombotic microangiopathy]

Thrombotic microangiopathy (TMA) is a frequent and severe complication in systemic lupus erythematosus (SLE). It is reported in almost 20-25% of renal biopsies of patients with lupus nephritis (LN) and is associated with a poor renal prognosis. We report the case of a patient suffering from an aggressive form of proliferative LN in association with thrombotic microangiopathy (TMA-LN), who was resistant to standard combined immunosuppressive treatment with corticosteroids and cyclophosphamide, as well as to plasma exchange (PEX). Eculizumab was given as a rescue therapy with an optimal clinical response. We performed a systematic review of the literature and identified 11 papers, published between 2011 and 2018, with a total of 20 patients, in which eculizumab was used, always as rescue therapy, to treat TMA-LN. All reported cases showed a positive clinical response to eculizumab with a high rate of remission. Even if sparse, available clinical cases and case series support the use of eculizumab in highly selected cases as rescue treatment for LN-TMA resistant to conventional combined immunosuppressive treatment.

[Extracorporeal renal replacement therapies in lithium intoxication]

Drug poisoning is a significant source of morbidity, mortality and health care expenditure worldwide. Lithium, methanol, ethylene glycol and salicylates are the most important ones, included in the list of poisons, that may require extracorporeal depuration. Lithium is the cornerstone of treatment for bipolar disorders, but it has a narrow therapeutic window. The therapeutic range is 0.6-1.2 mEq/L and toxicity manifestations begin to appear as soon as serum levels exceed 1.5 mEq/L. Severe toxicity can be observed when plasma levels are more than 3.5 mEq/L. Lithium poisoning can be life threatening and extracorporeal renal replacement therapies can reverse toxic symptoms. Currently, conventional intermittent hemodialysis (IHD) is the preferred extracorporeal treatment modality. Preliminary data with prolonged intermittent renal replacement (PIRRT) therapies - hybrid forms of renal replacement therapy (RRT) such as sustained low efficiency dialysis (SLED) - seem to justify their role as potential alternative to conventional IHD. Indeed, SLED allows rapid and effective lithium removal with resolution of symptoms, also minimizing rebound phenomenon.

P0181PERSISTENT C3 HYPOCOMPLEMENTEMIA AND MODERATE TUBULOINTERSTITIAL SCARRING AS EARLY PREDICTORS OF END-STAGE RENAL DISEASE IN LUPUS NEPHRITIS

Background and Aims

The prognosis of lupus nephritis (LN) has become progressively more favorable thanks to the introduction of cyclophosphamide and mycophenolate as the mainstay of induction of remission treatment regimens. However, 10-15% of patients still progress to end-stage renal disease (ESRD). Early predictors of ESRD, i.e. in the first six months between kidney biopsy and the completion of induction, are currently limited to few histological and clinical features: ≥ 25% interstitial fibrosis and tubular atrophy (IFTA), fibrinoid necrosis, fibrous crescents, and thrombotic microangiopathy (TMA) [Rijnink EC et al CJASN 2017; Song D Arthritis Res Ther 2013]; lack of decrease in proteinuria &lt; 0.5 g/24-h at 3 and 6 months from kidney biopsy [Tamirou F Ann Rheum Dis 2016], baseline GFR ≤ 90 ml/min/1.73 m2, lack of decrease in urinary protein-to-creatinine ratio (UPCR) &lt; 1 and anti-dsDNA positivity at the end of induction [Dall’Era M Lupus Sci Med 2015]. In this study we sought to identify further clinical and histological predictors of ESRD in LN.

Methods

Adult patients diagnosed with LN between 1995 and 2018 in two centers (NIAMS, Bethesda, Maryland, USA, and Nefrologia, AOU di Parma, Italy) were retrospectively identified. Patients with available serum C3 and C4 levels at the time of biopsy and 6 months thereafter, and a follow-up of at least 6 months, were included. Baseline and follow-up data (until March 2019) including age, sex, ethnicity, clinical, histological and laboratory findings were collected. Histology slides were reviewed by an experienced renal pathologist and biopsies re-scored using the ISN/RPS classification and NIH activity and chronicity indices. Distinct histological features were assessed individually (e.g. TMA). Persistent C3 hypocomplementemia was defined as decreased serum C3 levels at the time of biopsy and after 6 months (i.e. after the completion of induction), with concurrent normal serum C4 levels at 6 months. Early renal recovery was defined as either an increase in eGFR above 60 in those with a baseline eGFR &lt; 60 ml/min/1.73 m2, or a 50% decrease in proteinuria in those with a baseline eGFR ≥ 60 ml/min/1.73 m2 and ≥ 0.5 g/24-h or g/g UPCR at the time of biopsy.

Variables were tested for their predictive power of death-censored ESRD in univariate and multivariate Cox regression models.

Results

74 patients (NIAMS n = 36; Parma n = 38) met our criteria. Median follow-up duration was 64 months (range 6-230). On univariate analysis, the following parameters predicted ESRD: Hispanic ethnicity; age at biopsy; persistent C3 hypocomplementemia; normalization of both C3 and C4; renal recovery after induction; NIH activity index; presence of TMA; ≥ 25% IFTA. Multivariate Cox regression models for ESRD were created considering statistically significant variables (p &lt; 0.05). In a model including Hispanic ethnicity, age at biopsy, and persistent C3 hypocomplementemia, the latter predicted ESRD with an HR of 5.22 (95% CI [1.33, 20.58] p = 0.018) when adjusting for renal recovery after induction. Upon including histological features in the model, persistent C3 hypocomplementemia, TMA, and the NIH activity index lost significance, while ≥ 25% IFTA predicted ESRD with an HR of 27.26 (95% CI [2.12, 350.54], p = 0.011).

Conclusion

In patients with LN, ≥ 25% IFTA at baseline biopsy is a predictor of ESRD, allowing for early risk stratification with the potential of informing treatment strategies. Where percent IFTA is unavailable or its assessment unreliable (e.g. inadequate biopsy specimen for tubulointerstitial assessment), persistent C3 hypocomplementemia represents a reliable and reproducible early predictor of ESRD, irrespective of early renal recovery after induction.

Computational Segmentation and Classification of Diabetic Glomerulosclerosis

BACKGROUND

Pathologists use visual classification of glomerular lesions to assess samples from patients with diabetic nephropathy (DN). The results may vary among pathologists. Digital algorithms may reduce this variability and provide more consistent image structure interpretation.

METHODS

We developed a digital pipeline to classify renal biopsies from patients with DN. We combined traditional image analysis with modern machine learning to efficiently capture important structures, minimize manual effort and supervision, and enforce biologic prior information onto our model. To computationally quantify glomerular structure despite its complexity, we simplified it to three components consisting of nuclei, capillary lumina and Bowman spaces; and Periodic Acid-Schiff positive structures. We detected glomerular boundaries and nuclei from whole slide images using convolutional neural networks, and the remaining glomerular structures using an unsupervised technique developed expressly for this purpose. We defined a set of digital features which quantify the structural progression of DN, and a recurrent network architecture which processes these features into a classification.

RESULTS

Our digital classification agreed with a senior pathologist whose classifications were used as ground truth with moderate Cohen's kappa κ = 0.55 and 95% confidence interval [0.50, 0.60]. Two other renal pathologists agreed with the digital classification with κ₁ = 0.68, 95% interval [0.50, 0.86] and κ₂ = 0.48, 95% interval [0.32, 0.64]. Our results suggest computational approaches are comparable to human visual classification methods, and can offer improved precision in clinical decision workflows. We detected glomerular boundaries from whole slide images with 0.93±0.04 balanced accuracy, glomerular nuclei with 0.94 sensitivity and 0.93 specificity, and glomerular structural components with 0.95 sensitivity and 0.99 specificity.

CONCLUSIONS

Computationally derived, histologic image features hold significant diagnostic information that may augment clinical diagnostics.

Exploring the multiparameter nature of EUV-visible wave mixing at the FERMI FEL

The rapid development of extreme ultraviolet (EUV) and x-ray ultrafast coherent light sources such as free electron lasers (FELs) has triggered the extension of wave-mixing techniques to short wavelengths. This class of experiments, based on the interaction of matter with multiple light pulses through the Nth order susceptibility, holds the promise of combining intrinsic ultrafast time resolution and background-free signal detection with nanometer spatial resolution and chemical specificity. A successful approach in this direction has been the combination of the unique characteristics of the seeded FEL FERMI with dedicated four-wave-mixing (FWM) setups, which leads to the demonstration of EUV-based transient grating (TG) spectroscopy. In this perspective paper, we discuss how the TG approach can be extended toward more general FWM spectroscopies by exploring the intrinsic multiparameter nature of nonlinear processes, which derives from the ability of controlling the properties of each field independently.

Polarization-state-resolved high-harmonic spectroscopy of solids

Attosecond metrology sensitive to sub-optical-cycle electronic and structural dynamics is opening up new avenues for ultrafast spectroscopy of condensed matter. Using intense lightwaves to precisely control the fast carrier dynamics in crystals holds great promise for next-generation petahertz electronics and devices. The carrier dynamics can produce high-order harmonics of the driving field extending up into the extreme-ultraviolet region. Here, we introduce polarization-state-resolved high-harmonic spectroscopy of solids, which provides deeper insights into both electronic and structural sub-cycle dynamics. Performing high-harmonic generation measurements from silicon and quartz, we demonstrate that the polarization states of the harmonics are not only determined by crystal symmetries, but can be dynamically controlled, as a consequence of the intertwined interband and intraband electronic dynamics. We exploit this symmetry-dynamics duality to efficiently generate coherent circularly polarized harmonics from elliptically polarized pulses. Our experimental results are supported by ab-initio simulations, providing evidence for the microscopic origin of the phenomenon.

High-harmonic generation in solids is related to the carrier dynamics and can be used to probe dynamic processes. Here, Klemke et al. show that the polarization states of high harmonics generated from silicon and quartz are determined by the crystal symmetries but can also be dynamically controlled.

A Case of Breast Angiosarcoma: Diagnostic Imaging and Review of the Literature

Primary angiosarcoma of the breast is a rare tumor, with approximately 170 cases reported in the literature (1-3, 10, 11, 15). Reports on the imaging characteristics of these tumors have been occasional until a recent review by Liberman et al. (11). Diagnostic imaging of the masses include mammographic and ultrasound examinations (5): the imaging characteristics of the tumor can be nonspecific and sometimes heterogeneous (11). Only recently was one case evaluated with magnetic resonance imaging (11).

We present the mammographic and sonographic features of a case of primary angiosarcoma of the breast with an inflammatory appearance.

Idiopathic retroperitoneal fibrosis and its overlap with IgG4-related disease

Retroperitoneal fibrosis (RPF) is a rare disease characterised by fibrous tissue proliferation in the retroperitoneum, with encasement of the ureters and large vessels of the abdomen as the most destructive of potentially severe complications. It can either be idiopathic, or secondary to infections, malignancies, or the use of certain drugs. The idiopathic form accounts for approximately 75% of the cases, and is usually responsive to immunosuppressive therapy. In recent years, the emergence of a new clinical entity, IgG4-related disease (IgG4-RD), shed light on many fibro-inflammatory disorders once thought to be separate clinical entities, although frequently associated in the so-called multifocal fibrosclerosis. Among these, together with sclerosing pancreatitis and cholangitis, pseudotumour of the orbit, idiopathic mediastinal fibrosis and other conditions, is idiopathic retroperitoneal fibrosis (IRF). Both IRF and IgG4-RD can be associated with a wide variety of disorders, usually governed by immune-mediated (and particularly auto-immune) mechanisms. In our review, we discuss the clinical and therapeutic challenges IRF presents to the internist, as well as the meaning of its recent inclusion in the IgG4-RD spectrum from a clinical practice standpoint.

Prognostic value of subclassification of T2 tumours in patients with gastric cancer

BACKGROUND

This study was designed to evaluate the prognostic value of tumour stage T2 subcategorization (T2a and T2b) in patients with gastric carcinoma.

METHODS

Clinicopathological details of a prospective series of patients who had radical resection of gastric adenocarcinoma in a single institution were analysed. Univariable and multivariable survival analyses were performed with the log rank test and Cox's model respectively.

RESULTS

Of 373 evaluable patients, 49 (13.1 per cent) had a T2a and 143 (38.3 per cent) a T2b tumour. At a median follow-up of 35.5 months, the 5-year overall survival rate was 73 and 31.1 per cent for patients with T2a and T2b lesions respectively (P < 0.001). On multivariable analysis, T stage remained an independent prognostic factor. Compared with T1a, the mortality risk for patients with T1b (hazard ratio (HR) 1.00; P = 0.992) and T2a (HR 0.97; P = 0.916) tumours was similar; by contrast, the risk of death associated with T2b (HR 1.81; P = 0.031) and T3 (HR 1.89; P = 0.038) lesions was significantly greater than for T1a tumours.

CONCLUSION

Subclassification of T2 tumours should be undertaken routinely in order to stratify patients with gastric cancer more accurately in terms of their mortality risk.