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Urinary isomorphic red blood cells for the prediction of disease severity and renal outcomes in MPO-ANCA-associated vasculitis: a retrospective cohort study



Hematuria is common in myeloperoxidase anti-neutrophil cytoplasmic antibody associated vasculitis (ANCA-MPO). Previous studies have mainly focused on urinary dysmorphic red blood cells and few have reported the clinical significance of isomorphic urinary red blood cells. Therefore, the main aim of this study was to assess the predictive yield  of urinary isomorphic red blood cells for disease severity and renal outcomes in patients with ANCA-MPO associated vasculitis.


A total of 191 patients with ANCA-MPO associated vasculitis with hematuria were retrospectively selected and were divided into two groups (with isomorphic red blood cells versus dysmorphic red blood cells) according to the percentage of isomorphic red blood cells on urinary sediment analysis. Clinical, biological and pathological data at diagnosis were compared. Patients were followed up for a median of 25 months and progression to end-stage kidney disease and death were regarded as main outcome events. Additionally, univariate and multivariate Cox regression models were used to estimate the risk factors for end-stage kidney disease.


Out of 191 patients, 115 (60%) had ≥ 70% and 76 (40%) had < 30% urine isomorphic red blood cells. Compared with patients in the dysmorphic red blood cell group, patients in the isomorphic red blood cell group had a significantly lower estimated glomerular filtration rate (eGFR) [10.41 mL/min (IQR 5.84–17.06) versus 12.53 (6.81–29.26); P = 0.026], higher Birmingham Vasculitis Activity Score [16 (IQR 12–18) versus 14 (10–18); P = 0.005] and more often received plasma exchange [40.0% versus 23.7% (P = 0.019)] at diagnosis. Kidney biopsies revealed a higher proportion of patients with glomerular basement membrane fracture in the isomorphic red blood cell group [46.3% versus 22.9% (P = 0.033)]. Furthermore, patients with predominant urinary isomorphic red blood cells were more likely to progress to end-stage kidney disease [63.5% versus 47.4% (P = 0.028)] and had a higher risk of death [31.3% versus 19.7% (P = 0.077)]. The end-stage kidney disease-free survival was lower in patients in the isomorphic red blood cell group (P = 0.024). However, urine isomorphic red blood cells ≥ 70% could not predict the presence of end-stage kidney disease in multivariate Cox analysis.


Myeloperoxidase-anti-neutrophil cytoplasmic antibody associated vasculitis patients with predominant urinary isomorphic red blood cells at diagnosis had more severe clinical manifestations and a higher risk of poor renal outcomes. In this respect, urinary isomorphic red blood cells could be viewed as a promising biomarker of ANCA_MPO vasculitis severity and progression.

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Fig. 1
Fig. 2

Data availability

The datasets used during the current study are available from the corresponding author on reasonable request.



Antineutrophil cytoplasmic antibody(ANCA)-associated vasculitis




Proteinase 3


Isomorphic red blood cells


Dysmorphic red blood cells




Enzyme-linked immunosorbent assay


High-power field


White blood cell


Red blood cell




Serum C3 levels


Serum C4 levels


Serum IgA levels


Serum IgG levels


Serum IgM levels


C-reactive protein


Erythrocyte sedimentation rate


Urinary albumin to creatinine ratio


Estimated glomerular filtration rate


Birmingham vasculitis activity score


Glomerular basement membrane




Plasma exchange


End-stage renal disease


Kidney replacement therapy


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This research was supported by the National Natural Science Foundation of China (81270786), Natural Science Foundation of Hunan Province (2020JJ4887), and Clinical Medical Technology Innovation Guidance Program of Hunan Province (2020SK53701).

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All authors have made substantial contributions to the completion of the work. Research idea and study design: FW, XL; Data acquisition: FW, YJ, FZ, LL, JT, LH, ZL, YJ, LD, HG, DS, GX; Statistical analysis and manuscript writing: FW, LL; Supervision: XL, JF, XH. All authors reviewed and approved the article.

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Correspondence to Xiaozhao Li.

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This study was approved by the medical ethics committee of Xiangya Hospital of Central South University (2019030598).

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Wang, F., Jin, Y., Zhou, F. et al. Urinary isomorphic red blood cells for the prediction of disease severity and renal outcomes in MPO-ANCA-associated vasculitis: a retrospective cohort study. J Nephrol 36, 2295–2304 (2023).

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