大量蛋白尿型IgA肾病激素疗效及临床病理分析

摘要

Objective IgA nephropathy (lgAN) is the most popular glomerular nephritis in China, which has complicated clinicopathologic features. IgAN with nephrotic syndrome is a special type with varied pathologic characteristics and is treated primarily with prednisone. This study was to investigate the effect of glucocorticoid in the treatment of IgAN with nephrotic syndrome , its relationship with the clinicopathologic features of the disease, and the rational use of prednisone. Methods We enrolled in this study 88 cases of IgAN with nephrotic syndrome diagnosed by renal hiopsy and treated by sufficient prednisone induction. According to the resulls of predrtisone trealment , the patients were divided into three groups : sustained remission ( SR) , relapse , and no remission ( NR) . The clinicopathologic features and medication methods were analyzed compared among different groups. Results Of the 88 patients, 22 (25.0％) belonged to the SR. 40 (45.5％) to the relapse, and 26 (29.5％ ) to the NR group. Compared with the SR and relapse groups , the NR group showed higher incidences of hypertention ( P ＜ 0. 05 ) , anemia ( P ＜ 0. 05 ) , heavy hematuria ( P ＜ 0. 01 ) and impaired renal function ( P ＜0. 01 ) , and more obvious proliferation of glomerular mesangial cells and segmental glomerular sclerosis ( P ＜ 0.01 ) . No statistically significant differences were found in the clinicopathologic features between the SR and relapse groups. The total rates of effectiveness and relapse were 70. 5％ and 64. 5％ , respectively. Relapse occurred in 55.0％ of the patients during the low-dose prednisone sustaining therapy, and in 75. 0％ during the 1-year follow-up. A remission rate of 72. 7％ was achieved by a second prednisone induction after recurrence during the low-dose therapy. Those with a single relapse received a longer-time low-dose prednisone therapy than before ( 18. 6 vs 6. 0 mo. P ＜ 0. 05 ) and showed a higher rate of assistant administration of immunosuppressant ( 88. 5％ vs 50. 0％ , P ＜ 0. 05 ) . Conclusion Glucocorticoid is applicable to the treatment of IgAN with nephrotic syndrome which is seemingly a mild condition , with high rates of hoth remission and relapse. However, the recurrence can be effectively prevented by prolonged low-dose prednisone sustaining therapy and timely and correct assistant medication of immunosuppressant.%目的 IgA肾病(IgA nephropathy,IgAN)是国内最常见的原发性肾小球疾病,其临床、病理表现复杂多样.目前将表现为肾病综合征者称为大量蛋白尿型IgAN.其病理表现轻重不一,治疗上多首选糖皮质激素(简称激素).文中分析IgAN患者采用激素的疗效与临床、病理特征之间的关系以及激素的合理使用.方法 选取经肾活检诊断为大量蛋白尿型IgAN并予足量激素诱导治疗的患者88例,依据激素诱导疗效分为持续缓解组、复发组、无效组,分析不同疗效组临床、病理特征及激素使用方法的差异.结果 88例患者中,持续缓解22例(25.0%)、复发40例(45.5%)、无效26例(29.5%).与持续缓解组和复发组相比,无效组高血压、贫血发生率高(P<0.05),镜下血尿更严重(P<0.01),肾功能损伤更多见(P<0.01),系膜细胞增殖、节段肾小球硬化等病变更突出(P<0.01),而持续缓解组与复发组临床、病理特征的差异无统计学意义.激素治疗大量蛋白尿型IgAN总有效率70.5%,复发率64.5%,其中55.0%的患者于小剂量激素维持治疗期间复发,75.0%于随访1年内复发.小剂量维持治疗阶段复发者再次诱导治疗持续缓解率达72.7%.单次复发患者重新诱导缓解后小剂量激素维持治疗时间较复发前延长[(18.6vs6.0)个月,P<0.05],且辅助用药率更高(88.5%vs50.0%,P<0.05).结论 糖皮质激素适用于类似微小病变的大量蛋白尿型IgAN,治疗缓解率高,复发率亦高.适当延长小剂量激素维持治疗时间,及时、正确地辅助用药可有效预防复发.