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Reliability of Histologic Scoring for Lupus Nephritis: A Community-based Evaluation

Richard M. Wernick, MD; David L. Smith, MD; Donald C. Houghton, MD; David S. Phillips, PhD; James L. Booth, MD; Douglas N. Runckel, MD; David S. Johnson, MD; Kevin K. Brown, MD; and Cynthia L. Gaboury, MD
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From Providence Medical Center, Portland Veterans Affairs Medical Center, Oregon Health Sciences University, St. Vincent Medical Center, and Good Samaritan Hospital, Portland, Oregon. Request for Reprints: Richard Wernick, MD, Providence Medical Center, 4805 Northeast Glisan Street, Portland, OR 97213. Acknowledgments: The authors thank Chris Siegenthaler for her expert assistance in manuscript preparation; P. Slopoko and Debra Miles for inspiration and support; and Howard A. Austin III for helpful discussion.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(8):805-811. doi:10.7326/0003-4819-119-8-199310150-00006
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Objective: To determine the reliability of the National Institutes of Health (NIH)-modified semiquantitative histologic scoring system for lupus nephritis.

Design: Cross-sectional study, repeated after 8 to 9 months.

Setting: Four community hospitals and one university medical center.

Participants: Five pathologists, all experienced in reading renal biopsy specimens, assessed 25 specimens that had been obtained from patients with a clinical diagnosis of systemic lupus erythematosus and showed diffuse proliferative glomerulonephritis.

Measurements: Biopsy specimens were scored independently and blindly by pathologists for components of nephritis chronicity and activity. Reliability was measured by percentage agreement, intraclass correlation coefficient or statistic, and individual reader effect on the group arithmetic mean.

Results: As scored by the readers, the mean chronicity index score varied from 2.3 to 4.8 on a 12-point scale (P = 0.001) and the mean activity index score varied from 5.8 to 11.4 on a 24-point scale (P = 0.0001). Pairs of readers gave scores within 1 point for the chronicity index and within 2 points for the activity index in 50% of cases, and risk group assignments based on chronicity index (three strata) and activity index (two strata) were concordant in 59% and 76% of cases, respectively. Intraclass correlation coefficients for inter-reader agreement were 0.58 for the chronicity index (P < 0.01) and 0.52 for the activity index (P < 0.01). Intrareader agreement was uniformly higher than inter-reader agreement, but mean intraclass correlation coefficients exceeded 0.70 for only 1 of the 10 index components. Repeated readings yielded chronicity index scores that were more than 1 point discordant in 45% of cases and activity index scores that were more than 2 points discordant in 43% of cases. Risk group assignment changed on the basis of chronicity index and activity index in 36% and 21% of cases, respectively.

Conclusions: In a nonreferral setting, the NIH-modified scoring system for lupus nephritis is only moderately reproducible and, if used to prognosticate renal outcome, may result in erroneous predictions of risk for renal failure and response to therapy.


Grahic Jump Location
Figure 1.
Reader effect on chronicity index scoring.

Each bar represents the mean chronicity index as scored by an individual reader minus the mean chronicity index of the group of readers. Hatched bars = first reading; open bars = second reading.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Reader effect on activity index scoring.

Each bar represents the mean activity index as scored by an individual reader minus the mean activity index of the group of readers. Hatched bars = first reading; open bars = second reading.

Grahic Jump Location




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