MMF联合糖皮质激素治疗伴肾功能损害的进展性IgA肾病的不同疗效的特点分析

摘要

目的：分析吗替麦考酚酯（Mycophenolatemofetil，MMF）联合糖皮质激素治疗伴肾功能损害的进展性IgA肾病时不同疗效的特点，探讨对疗效有预测价值的临床、病理特征。方法整群选择2010年2月—2013年6月在无锡市人民医院经肾脏病理检查诊断的原发性IgA肾病42例，对符合进展性IgA肾病特点，同时伴有肾功能损害，并接受MMF联合糖皮质激素治疗的病例进行回顾性分析研究。结果共42例患者纳入该研究，男性（21例）占61.9%，CKD3～4期患者占74.6%，平均eGFR（50.29±19.04） mL/min·1.73m2，平均蛋白尿（3.15±1.73） g/d；42例（100.0%）均予MMF联合泼尼松治疗，其中CR21例（50.0%），PR15例（35.6%），NR6例（14.3%），治疗有效率85.6%。比较发现，NR患者基线蛋白尿高于CR、PR患者（P<0.01），血浆白蛋白低于后两者（P<0.05）。肾活检时，NR组血肌酐最高（P<0.05）、eGFR水平最低（P<0.05）。NR患者病理上肾小管萎缩、间质纤维化最严重（P<0.01），细胞性新月体最少见（P<0.01）。单因素、多因素COX回归分析结果表明，蛋白尿>3.5g/d、eGFR<30 mL/min·1.73m2、严重肾小管间质慢性病变为疗效差的独立危险因素。细胞性新月体为疗效良好的独立预测因素（P<0.001）。不良反应在疗效差的患者中更多见（P<0.05）。结论MMF联合糖皮质激素治疗伴肾功能损害的进展性IgA肾病总有效率高，安全性好。尿蛋白>3.5 g/d、eGFR<30 mL/min·1.73m2、严重肾小管间质慢性损害均为疗效差的独立危险因素。细胞性新月体为疗效良好的独立预测因素。%Objective To analyze the different efficacies of MMF combined with prednisone for progressive IgA nephropathy with renal impairment and investigate the clinicopathological features that can be the predictive markers of the efficacies. Methods 42 patients with biopsy-proven primary IgA nephropathy treated by MMF combined with prednisone in Wuxi People's Hospital from February 2010 to June 2013 were enrolled in this retrospective analysis, and they also had charac-teristics of progressive IgA nephropathy accompanied by renal dysfunction. Results Of the 42 cases enrolled in study, men (21 cases) accounted for 61.9%, CKD3-4 patients accounted for 74.6%, with an average eGFR(50.29 ± 19.04)mL/min.1.73㎡and an average proteinuria(3.15 ± 1.73)g/d. All the 42 cases(100.0%) were treated with MMF combined with prednisone. The complete remission (CR), partial remission (PR) and no remission (NR) rate was 50.0%(21 cases), 35.6%(15 cases) and 14.3%(6 cases) respectively. The treatment efficiency was 85.6%. Compared to the responders (CR and PR groups), non-re-sponders(NR group) got higher baseline proteinuria(P<0.01) and lower serum albumin(P<0.05). Among the three groups at renal biopsy, NR group showed the highest serum creatinine(P<0.05) and lowest eGFR(P<0.05). Besides, renal tubular atro-phy and interstitial fibrosis appeared much severer in NR group(P<0.01), of them cellular crescents performance was rarer to be seen (P<0.01). Both univariate and multivariate COX regression analysis showed that proteinuria>3.5g/d, eGFR<30mL/min﹒1.73m2, severe renal tubular atrophy were independent risk factors for poor effects. Cellular crescents was an indepen-dent predictor of satisfactory effect(P<0.001). Adverse effects were more usually seen when there was poor therapy effect(P<0.05). Conclusion MMF combined with prednisone for progressive IgA nephropathy with renal impairment got good effect and safety. Urine protein >3.5g/d, eGFR<30mL/min﹒1.73m2, severe chronic damage of renal tubular were independent risk factors of poor curative effect. Cellular crescent performance was an independent predictor of good curative effect.