激素抵抗肾病综合征临床危险因素分析

Risk factors for steroid resistant nephrotic syndrome

目的探讨激素抵抗肾病综合征(SRNS)相关临床危险因素。方法回顾性调查2002年6月至2010年6月间上海交通大学医学院附属瑞金医院肾脏科115例原发性肾病综合征(PNS)患者的临床资料,包括性别、年龄、体重指数(BMI)、血压、尿液分析、尿蛋白定量、血生化指标、尿α1微球蛋白(α1-MG)等,以及随访数据,半定量评估肾脏病理改变,应用多因素Logistic回归模型进行危险因素分析,通过绘制受试者工作特性曲线(ROC)评价检验指标在预测SRNS时的敏感度和特异度。结果 115例患者中SRNS组48例,血肌酐(Scr)、血压、α1-MG均高于非SRNS组,SRNS组肾小球节段硬化比例高、肾小管间质病变程度重;Logistic回归分析显示,血Scr和尿ln(α1-MG)是影响PNS激素抵抗的独立危险因素,OR(95%CI)分别为1.02(1.00～1.03,P=0.02)和1.67(1.04～2.68,P=0.03),血Scr与肾小管间质病变呈正相关,尿α1-MG则独立于肾组织病理与其无明显相关性;血scr和尿ln(α1-MG)的ROC曲线下面积分别为0.70和0.72,最佳截点分别为83μmol/L(敏感度为68.75%,特异度为64.18%)和13.3 mg/L(敏感度为73.33%,特异度为68.63%)。进一步以Scr和尿ln(α1-MG)均小于上述截点为参照,当血scr>83μmol/L时,激素抵抗的风险增加4.73倍(95%CI 1.17～19.02),尿α1-MG>13.3 mg/L时风险增加5.40倍(95%CI 1.38～21.21),当血scr及尿ln(α1-MG)均超过上述截点时,SRNS的风险增加16.88倍(95%CI 4.87～58.47)。结论 PNS患者在治疗前联合评估其肾功能及尿α1-MG对判断激素疗效具有重要的临床意义。

Objective To explore the risk factors associated with steroid resistant nephrotic syndrome(SRNS).Methods The clinical,pathological and follow-up data of 115 cases with primary nephrotic syndrome(PNS) retrospectively were analyzed including gender,age,body mass index(BMI),blood pressure,urinalysis,urine protein,blood biochemistry,urine α1microglobulin(α1-MG),etc.Multivariate Logistic regression was applied to analyze the risk factors of SRNS.The sensitivity and specificity of the indicators were evaluated by plotting the receiver operating characteristics curve.Results There were 48 SRNS patients out of all the 115 cases in the SRNS group.Serum creatinine(Scr),blood pressure and urinary α1 microglobulin(α1-MG) were higher in the SRNS group than in the non-SRNS group.The SRNS group had a higher proportion of glomerular segmental sclerosis and severer tubulointerstitial lesions.Mulitiple logisitic regression analysis showed that Scr(OR =1.02,1.00-1.03) and urine ln(α1-MG)(OR =1.67,1.04-2.68) were independent risk factors of the hormone therapy after being adjusted by gender,BMI,hemoglobulin,uric acid,albumin and urine protein,and there was positive correlation between serum creatinine and the degree of tubulointerstitial lesions.However,no significant relation was found between urinary α1-MG and the pathological evaluation.The area under the ROC curves was 0.70 for Scr and 0.72 for ln(α1MG),with a cut-off value of 83 μmol / L(sensitivity: 68.75%;specificity: 64.18%) and 13.3 mg / L(sensitivity: 73.33%;specificity: 68.63%),respectively.In addition,compared to patients with lower Scr(< 83 μmol / L) and lower urinary ln(α1-MG)(< 13.3 mg / L),patients with higher Scr(OR = 4.73,1.17-19.02),or higher ln(α1-MG)(OR = 5.40,1.38-21.21),or both(OR = 16.88,4.87-58.47) were associated with increased risk of SRNS.Conclusion Assessment of renal function and urinary α1-MG in patients with PNS before treatment is of clinical significance to predicting response to the steroid therapy.