拟诊高血压肾硬化患者的临床病理分析

Clinicopathological analysis of hypertensive nephrosclerosis patients diagnosed clinically

目的探讨拟诊高血压肾硬化(HN)患者的临床特征及影响预后的因素,以期提高临床对该病诊断及治疗的认识。方法回顾性分析我科63例最初拟诊HN且有肾活检诊断的患者的临床资料。根据肾脏病理学结果分为原发性肾炎(PN)组、良性肾小动脉硬化症(BN)组及恶性肾小动脉硬化症(MN)组,比较各组间临床参数及组织学特征。对确诊HN的患者分析影响其预后的临床及病理因素。结果 63例临床拟诊为HN的患者经肾组织活检病理诊断,37例 (58．7％)为BN;12例(19．0％)为MN;14例(22．2％)为PN,HN诊断符合率为77．7％。BN组患者男性较多,年龄较大,高血压家族史比例及高血压病程明显高于PN组,而PN组尿蛋白定量高于BN及MN组。MN组左心室心肌重量指数(LVMI)高于PN组。BN组视网膜病变主要为0-Ⅱ级,占78％,而MN组则主要为Ⅲ～Ⅳ级。PN组球性硬化肾小球比率及小管慢性化指数(CI)积分均高于MN及BN组。MN及BN组肌内膜细胞增殖、小动脉玻璃样变等血管病变均较PN组明显,其中BN组改变最为显著。多因素回归分析提示收缩压(SBP)、尿蛋白定量、尿酸(UA)、总胆固醇(TC)是影响肾脏病进展的危险因素,优势比分别为2．563、2．467、2．323、2．357。结论临床拟诊HN的患者不能排除PN。部分HN与PN患者临床表现相似,单纯依据病史及实验室检查难以区分。肾组织病理检查是确诊的最佳手段。SBP、尿蛋白、TC、UA等因素可加速HN的病变进展。

Objective To explore the clinicopathological characteristics and prognostic risk factors of hypertensive nephmsclemsis. Methods A retrospective study was performed on 63 hypertensive patients with renal injury. The clinical date such as age, gender, family medical history, blood pressure, urine protein excretion, serum indicates, eyeground and echecardiography were analyzed. Patients were divided into 3 groups according to histological diagnosis：benign nephrosclerosis （BN）, malignant nephrosclerosis （MN） and primary nephritis （PN）. The clinicopathological data were compared among three groups. The risk and prognostic factors were further analyzed for the patients confirmed by pathology. Results Among 63 patients,49 （77.8%） were diagnosed as HN, including 12 （19.0%） of MN, 37（58.7%） of BN, and 14 （22.2%） as PN. More males, older, frequent hypertension family history and longer duration were observed in BN group, whereas lower urine protein excretion was found in BN and MN groups as compared to PN group. MN group exhibited higher left ventricular mass index （LVMI）than PN group. 78% BN patients presented grade 0 ～Ⅱ hypertensive retinopathy and most of MN patients grade Ⅲ～ Ⅳ. The frequency of globally sclerotic glomemli increased significantly in PN group as compared to BN and MN groups, and so did the score of chronic index of renal pathology. The severity of vascular injury, assessed by the myointimal proliferation, was higher in BN than that in PN. Systolic blood pressure （odds ratio,OR 2.563）.urine protein excretion （OR 2.467）, uric acid （OR 2.323） and total cholesterol （OR 2.357） were independent risk factors for the disease progression by multivariate analysis. Conclusions HN diagnosed clinically without renal pathological evidence can not exclude primary nephritis. Further biopsy-based study is necessary to establish the true dimension of HN. High systolic blood pressure, urine protein excretion, total cholesterol and uric acid promote the progress of renal disease.