过敏紫癜性肾炎肾损害发生时间与临床病理的联系

Correlation of nephropathy-purpura interval to clinicopathologic characteristics in Henoch-Schnlein purpura patients with renal involvement

目的 :回顾性分析过敏紫癜性肾炎 (HSPN)患者肾脏损害发生时间不同与临床病理及预后的联系。 方法 :1983年 1月至 2 0 0 1年 12月在我院肾活检确诊HSPN、明确记载皮肤紫癜与肾损害发生时间 ,并定期随访的患者 14 5例。分为三组 :组 1(肾损害早发组 ,n =84 ) ,肾炎在皮肤紫癜出现后 1个月内起病 ,病程中皮肤紫癜仅出现 1次 ;组 2 (反复紫癜 /肾损害迟发组 ,n =4 8) ,皮肤紫癜发作至少 2次或皮损发生 1个月后出现肾损害 ;组 3(肾损害首发组 ,n =13) ,肾损害出现在皮肤紫癜前。预后判断 ,正常 :无任何症状 ,尿检正常 ,肾功能正常 ;轻度尿检异常 :蛋白尿 (<1g/2 4h)或镜下血尿 ,肾功能正常 ,无高血压 ;恶化 :蛋白尿 (>1g/2 4h) ,肉眼血尿 ,高血压和(或 )肾功能不全。 结果 :三组间患者起病年龄、关节、胃肠受累率无显著性差异。组 1患者肾损害表现为尿检异常 /孤立性肉眼血尿 ,高血压和肾功能不全发生率低 ,肾活检病理以系膜增生为主 ,可伴少量细胞性新月体形成。组 2患者以中等量、大量蛋白尿多见 ,低白蛋白血症 2 2 9% ,病理上细胞性、细胞纤维性新月体、球囊粘连比例高。组 3患者病程最长 ,肾损害重 ,高血压发生率 15 4 % ,肉眼血尿发生率 38 5 % ,大量蛋白尿占 2 3 1% ,3例以急进性肾炎起病 。

Objective:To study the relationship between nephropathy-purpura interval and clinical man ifestations, and prognosis in Henoch-Schnlein purpura patients with renal inv olvement (HSPN). Methodology:145 patients with HSPN who received at least an renal biopsy were followed up fo r an average time of 42.5 months. According to the record of renal damage-pur pura interval, the patients were divided to three groups: group 1(n=84), HSP N onset within one month after isolated purpura; group 2 (n=48), recurrent p urpura or purpura 1 month more proceeding HSPN; and group 3 (n=13), HSPN pro ceeding purpura. Clinical outcomes were grades as follows: Normal, i.e., symp tom free with normal urinalysis ( hematuria negative and proteinuria <0.4 g/24h r) and normal SCr;Minor urinary abnormality, i.e., proteinuria 0.4～1 g/24hr with or without hematuria, without hypertension and increased SCr;Deterioratio n, i.e., proteinuria >1 g/24hr, gross hematuria, with hypertension or renal in sufficiency. Results:Patients in group 1 showed mild urinary abnormality or isolated gross hematuria with normal blood pressure and SCr level. Renal biopsy revealed mesangial proli feration and few cellular crescent formation. Compared with groups 1, patients in group 2 developed renal damage lately. Moderate or massive proteinuria occur red more frequently in group 2. Hypoalbuminia occurred in 11 patients(22.9%) . Capsule adhesion, and cellular/fibrous crescent were more sever in group 2 th an in group 1. In group 3,hypertension was observed in 15.4% of patients, gr oss hematuria 38.5%, massive proteinuria 23.1%. Acute and chronic lesion was observed. In group 1, the outcome of 61 patients(72.6%) were graded as normal, 14 patients (16.7%) as minor urinary abnormalities,and 9 patients (10.8%) as deterioration. In group 2, the outcome of 20 patients (41.7%) were graded as normal, 14 (29.2%) as minor urinary abnormalities,and 14 (29.1%) as deteriora tion. Whereas in group 3, the outcome of 7 patients (53.8%) were greaded as n ormal, 6 (46.2%) achieved deterioration. Significant difference in probability of deterioration was found among the three groups of patients(P<0.01). Conclusion:These findings suggest that interval between the onset of renal damage and purpu ra, or recurrence of purpura might be associated with the outcomes. Patients wi th recurrent purpura, or prolonged history of purpura over 1 month proceeding re nal onset, or renal onset before purpura, represent more severe subgroups of HSP .