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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 368-369
Necrotic crescentic glomerulonephritis and IgA nephropathy: Lee-hass classification revisited


Associate Professor, Histopathology Department, Sindh Institute of Urology and Transplantation, Karachi - 74200, Pakistan

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Date of Web Publication28-Feb-2012
 

How to cite this article:
Mubarak M. Necrotic crescentic glomerulonephritis and IgA nephropathy: Lee-hass classification revisited. Saudi J Kidney Dis Transpl 2012;23:368-9

How to cite this URL:
Mubarak M. Necrotic crescentic glomerulonephritis and IgA nephropathy: Lee-hass classification revisited. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Aug 29];23:368-9. Available from: http://www.sjkdt.org/text.asp?2012/23/2/368/93182
To the Editor ,

I have read with interest the article by Jabur WL published recently in your esteemed journal describing a case of an adult female who presented clinically with acute glomerulo-nephritis (GN) and the nephrotic syndrome, and was diagnosed to have predominantly mi­nimal change disease (MCD) with concurrent Henoch-Schonlein Purpura (HSP). [1] Indeed, dual pathologies, especially in association with IgA nephropathy (IgAN), on renal biopsy are not infrequent. But, there are many points in the subject study that need clarification.

The term "necrotic crescentic GN (CresGN)" used by the author in the title as well as the text is incorrect, as this case did not fulfill the criteria for the diagnosis of CresGN, which requires involvement of >50% of the glome-ruli with crescents. Moreover, the title refers to IgAN, and this is in contradiction with the final diagnosis described by the author, namely MCD with concurrent HSP. Indeed, it is worth knowing the opinion of the pathologist on the biopsy diagnosis rendered in this case.

The classification discussed in the case, i.e. Lee-Hass classification, is also incorrectly re­ferred to in the text and title. I guess the author wants to discuss the refined classification by Lee HS et al. [2] The Hass classification is dis­tinct from the above and also relates to the pathologic classification of IgAN. [3] These are two completely different classification schemes. Moreover, the grade of the case under discussion according to the above classification is not provided. It is also not stated whether the prognostic prediction of the subject case by the above classification was useful or not. There is no information on the duration of treatment, type of response and the follow-up data. Without this information, it is impossible to assess the prognostic value of any classifica­tion scheme.

The author has rightly pointed out that the lesion of capillaritis associated with IgAN has not been investigated in detail in the recent literature. However, this is not true for the crescentic lesions, which have been studied in sufficient detail by many authors. [4]

The intensity and peripheral capillary wall extension of IgA deposits on immunofloure-scence is not given. The later feature is usually associated with segmental capillary necrosis, as in HSP.

In the third paragraph of discussion, there are contradictory statements about the vasculitic nature of IgAN. In the beginning, it is stated that "it is inappropriate to classify IgAN as a vasculitic process," but later on in the same paragraph there is argument that "we believe that in IgAN, crescentic lesions reflect a pe­culiar vascular involvement" etc. In the same paragraph, the author also states that the Lee classification seems to delineate the grades of IgAN based on chronicity, which is not cor­rect. On the other hand, it lumps both the active and the chronic lesions together in single grades and, hence, the need for a newer internationally acceptable classification. [5]

The comment by the author that the crescents have not been addressed in the classification by Lee et al is not warranted, as grades II-V are defined mainly on the extent of crescentic involvement of the glomeruli among other lesions. [2]

With the recent promulgation of "The Oxford classification of IgAN," it is advisable to use this classification for the disease. It is simple, easy to apply, fairly reproducible and, most important of all, pre-validated clinically before its formulation. This combination of features is rare in other renal classifications in use cur­rently. Indeed, this classification has all the potential to serve as the role model for classi­fying other renal diseases. [6]

 
   References Top

1.Jabur WL. Necrotic crescentic glomerulo-nephritis and IgA nephropathy: Lee-Hass classification revisited. Saudi J Kidney Dis Transpl 2011;22(4):784-7.  Back to cited text no. 1
    
2.Lee HS, Lee MS, Lee SM, et al. Histological grading of IgA nephropathy predicting renal outcome: revisiting H.S. Lee's glomerular grading system. Nephrol Dial Transplant 2005; 20:342-8.  Back to cited text no. 2
    
3.Haas M. Histologic subclassification of IgA nephropathy: a clinicopathologic study of 244 cases. Am J Kidney Dis 1997;29:829-42.  Back to cited text no. 3
    
4.Tumlin JA, Madaio MP, Hennigar R. Idio-pathic IgA nephropathy: Pathogenesis, histo-pathology, and therapeutic options. Clin J Am Soc Nephrol 2007;2:1054-61.  Back to cited text no. 4
    
5.Cattran DC, Coppo R, Cook HT. et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int 2009;76:534-45.  Back to cited text no. 5
    
6.Mubarak M. The Oxford classification of IgA nephropathy: a role model for classifying other renal diseases. Saudi J Kidney Dis Transpl 2011;22(5):897-900.  Back to cited text no. 6
    

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Correspondence Address:
Muhammed Mubarak
Associate Professor, Histopathology Department, Sindh Institute of Urology and Transplantation, Karachi - 74200
Pakistan
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PMID: 22382242

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