Pathologic classification of lupus glomerulonephritis by sammyc2007

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									Pathologic classification of lupus
       glomerulonephritis
The primary clinical purposes for pathologic classification
system are to:
     Facilitate communication:
         Between pathologists
         Between pathologists and clilinicalans
         Between clinicians
         In understanding the literature
    Facilitate clinical management:
        Guiding treatment
        Suggesting prognosis
        Indicating an etiology or pathogenic mechanism
Baldwin’s morphologic classification
         of lupus nephritis
   Mesangial lupus nephritis
   Focal proliferative lupus nephritis
   Diffuse proliferative lupus nephritis
   Membranous lupus nephritis

  *Mesangial lupus nephritis was add in a 1977 publication (Am J
    Med 62:12-30, 1977) to the other three categories that were
    published in 1970 (Ann Intern Med 73:929, 1970)
Who classified lupus nephritis?

       “Original WHO Classification”
    Buffalo, NY, 1974; or Geneva, 1975

     “Modified WHO Classification ”
ISKDC, Paris, 1980 (Churg and Sobin, 1982)

      “Modified WHO Classification ”
            Jacob churg 1995
 Sinniah and Feng, Clin, Nephrol. 6:340-51, 1976
(“preliminary histologic categories put forward by the WHO committee on
   Morphologic classification and Nomenclature or Renal diseases,
   Geneva, June, 1975 ”)


 Minimal (“nil”) lesion (normal by light microscopy)
 Minimal lesion with mesangial hypercellularity
 Focal and segmental glomerulonephritis
 Membranous glomerulonephritis
 Diffuse proliferative glomerulonephritis
 Diffuse membranoproliferative glomerulonephritis
Appel, Silva, Pirani, et al, Medicine 57:371-410,1978
     (“according to a classification proposed by the WHO ”)


    Class I. normal
            normal by LM, IM and IF
    Class II. Messangial changes
            A .minimal alterations
                (normal by LM, mesangial deposits by IF and EM)
            B. mesangial glomerulitis (mesangial hypercellularity)
    Class III. Focal and segmental proliferative glomerulonephritis
               (<50% glomeruli involved)
    Class IV. Diffuse proliferative glomerulonephritis
               (<50% glomeruli involved)
    Class V. membranous glomerulonephritis
              Pure
              Mixed patterns (such as Class III associated with Class V)
Jacob churg, 1982 (based on modifications at the ISKDC):
  “WHO morphologic classification of Lupus Nephritis”
         I. normal
                  a. Nil (by all techniques)
                  b. normal by LM but deposits by EM or IF
         II. Pure mesangial alterations (mesangiopathy)
                  a. mesangial widening mild hypercellularty
                  b. moderate hypercellularity
         III. Focal segmental glomerulonephritis
                  a. active necrotizing lesions
                  b. active and sclerosing lesions
                  c. sclerosing lesions

         IV. Diffuse glomerulonephritis
                  a. without segmental lesions
                  b.c. and d. like a.b and c. above
         V. diffuse membranous glomerulonephritis
                  a. pure
                  b. associated with category II
                  c. associated with actegory III
                  d. associated with category IV
         VI. Advanced sclerosing glomerulonephritis
                  Jacob Churg 1995:
WHO morphologic classification of Lupus nephritis (modified)

          I. Normal
                 a. nil( by all techniques)
                 b. normal by LM but deposits by EM or IF
          II Pure Mesangial Alteration (Mesangiopathy)
                 a. mesanglal widening mild hypercellularity
                 b. moderate hypercellularity
          III Focal Segmental Glomerulonephritis
                 a. active necrotizing lesion
                 b. active and sclerosing lesions
                 c. sclerosing lesions
          IV. Diffuse Glomerulonephritis
                 a. without segment lesions
                 b. c. and d, like A, B, and C above
          V. Diffuse Membranous Glomerulonephritis
                 a. pure
                 b. associted with category II
          VI. Advanced Sclerosing Glomerulonephritis
Controversies in WHO classification (WHO I and II )

Majority approach               Minority approach
 Class I: no lesion by LM,      IA. No lesion by LM, EM or
  EM, IM                          IM
                                 IB. no lesion by LM but
                                  mesangial deposits by EM
                                  and/or IM

 Class IIA. no lesion by LM,    IIA. mild mesangial
  but mesangial deposits by       hypercellularty
  IM and/or EM
                                 IIB. moderate mesangial
       IIB. mesangial
  hypercellularty                 hypercellularity
Controversies in WHO classication (WHO III and IV)

Majority apporach                    Minority approach
Class III :focal GN affecting <50%   Segmental GN affecting
           of glomeruli              <50% or >50% of glomeruli

Class IV: diffuse GN affeceting >    Diffuse non-seegmental GN
          50% of glomeruli           Affecting <50 % of glomeruli
Class V: membranous GN               Membranous GN
   A. no hypercellularity             A. no hypercellularity
   B. plus class II                   B. plus class II
                                      C. plus class III
                                      D. plus class IV
Mixed class III or IV plus V
Anyone WHO isn’t confused really
 doesn’t understand the situsion.


        Edward R. Murrow
 Proposal of the international
society of nephrology and renal
 pathological society working
 group on the classification of
   lupus glomerulonephritis
  “The major objective is to standardize definitions,
emphasize clinically relevant lesions, and encourage
uniform and reproducible reporting between centers.”
  2002 ISN/RPS Consensus Conference on the
  Classification of Lupus Nephritis (preliminary)

 Class I. Minimal mesangial lupus glomerulonephritis (LGN)
 Class II. Mesangial proliferative LGN
 Class III. Focal LGN ( involving < 50 % of glomeruli)
 Class IV.Diffuse LGN ( involving 50% or > glomeruli)
 Class V. Membranous LGN
 Class VI.Advanced sclerotic LGN ( >90 % sclerotic glomeruli )

*for classes III and IV, the diagnosis should include one of the following: with active
    lesions/with active and chronic lesions/Inactive with scars
*for classes III and IV, the diagnosis should include the percentage of glomeruli with
    fibrinoid necrosis and/or cellular crescents when present
*for class IV, the diagnosis should include one of the following: predominantly
    segmental (IV-S)/predominantly global (IV-G)
*class V may occur in combination with III or IV in which case both will be diagnosed
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)


 Class I. Minimal mesangial lupus glomerulonephritis



 Normal glomeruli by LM but mnesangeial immune
 deposits by IF and/ or EM.
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)
    Class II. Mesangial proliferative LGN



    Purely mesangial hyhpercellularity of any degree or
     mesangial matrex expansion by LM with immune
     deposits, predominatly mesangial with none or few,
     isolated subepithelial and/or subendothelial deposits
     by IF and/or EM not visible by LM.
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)

Class II. Mesangial proliferative lupus glomerulonephritis


Purely mesangial hyhpercellularity of any degree or
 mesangial matrex expansion by LM with immune deposits,
 predominatly mesangial with none or few, isolated
 subepithelial and/or subendothelial deposits by IF and/or
 EM not visible by LM.
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)
   Class III. Focal lupus glomerulonephritis

   Active or inactive focal , segmental and /or global endo- and
   /or extracapiliary GN, typically with focal, subendothelial
   immune extracapillary GN, with or without focal or diffuse
   mesangial alterations.

   III (A)        Active focal proliferative LGN
   III (A/C)      Active and sclerotic focal proliferative LGN
   III (C)        Inactive sclerotic focal LGN

*Indicate the proportion of glomeruli with active and with sclerotic lesions
*Indicate the proportion of glomeruli with fibrinoid necrosis and/or cellular crescents
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)
   Class IV. Diffuse segmental (IV-S) or global (IV-G) LGN

   Active or inactive diffuse (50% or more involved glomeruli),
   segmental or global endo- or extracapiliary GN with diffuse
   subendothelial immune deposits, with or without mesangial
   alterations. This class is divided into diffuse segmental (IV-S) when
   >50% of the involved glomeruli have segmental lesions, and diffuse
   global (IV-G) when >50% of the involved glomeruli have ealobal
   lesions.

   IV (A) Active diffuse segmental or global proliferative LGN
   IV (A/C) Diffuse segmental or global proliferative & sclerotic LGN
   IV (C) Diffuse segmental or global sclerotic LGN

*Indicate the proportion of glomeruli with active and with sclerotic lesions
*Indicate the proportion of glomeruli with fibrinoid necrosis and/or cresents
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)

 Class V. membranous LGN

 Numerous global or segmental subepithelial
 immune deposits or their morphologic sequelae by
 LM and/or IF and/or EM with or without mesangial
 alterations.

 May occur in combination with III or IV in which
 case both will be diagnosed
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)


Class VI. Advanced sclerotic lupus glomerulonephritis



90 % or > glomeruli globally sclerosed without
 residual activity
2002 ISN/RPS Consensus Conference on the
Classification of Lupus Nephritis (preliminary)
 Class I     Minimal mesangial lupus
    glomerulonephritis (LGN)
   Class II Mesangial proliferative LGN
   Class III Focal LGN (Involving < 50% of glomeruli)
   Class IV Diffuse LGN (Involving >= 50% gloeruli,
    IV-S and IV-G)
   Class V Membranous LGN
   Class VI Advanced sclerotic LGN (> 90% sclerotic
    glomeruli)
                       References
1.   Slnnlah R, Feng PH: Lupus nephritis: correlation between light,
     electron microscopic and immunofluorescent findings and renal
     function. Clinical Nephrol 6:340-351, 1976
2.   Appel GB, Silva FG, Pirani CL: Renal Involvement In systemic lupus
     erythematosus (SLE): a study of 56 patients emphasizing histologic
     classification. Medicine 75:371-410, 1978
3.   Churg J, Sobin LH: Renal disease: Classification and atlas of
     glomerular disease. Tokyo, Igaku-Shoin, 1982
4.   Churg J, Bernstein J, Glassock RJ: Renal disease: classification and
     atlas of glomerular diseases, second edition. New York, Tokyo,
     Igaky-Shoin, 1995
5.   Weening JJ, D’Agati VD, Schwartz M, Seshan SV, et al.:
     Classification of gloerulonephritis in systemic lupus erythematosus,
     in preparation, 2003

								
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