拟诊高血压肾硬化的非良性肾小动脉硬化症的临床及病理学分析

Clinical and pathological characteristics in patients with clinically presumed hypertensive nephrosclerosis

目的探讨拟诊高血压肾硬化（HN）患者的临床特征,以期提高对良性肾小动脉硬化症（BN）及类似疾病的认识.方法回顾性分析我科63例HN患者年龄、性别、家族史、血压、尿蛋白排泄、血清学各项指标以及眼底、心脏结构等临床参数.通过肾脏病理学检查明确诊断,分析比较各组间临床参数差异及组织学特征.结果依据病理诊断将患者分为BN（35例）、恶性肾小动脉硬化症（MN,12例）、原发性肾炎（PN,10例）、局灶节段性肾小球硬化症（FSGS,6例）四组.10例PN患者中IgA肾病7例（11.1%）,系膜增生性肾炎2例（3.2%）,间质性肾炎1例（1.6%）,HN诊断符合率为74.6%.BN组患者男性居多,年龄高于PN、FSGS组;高血压家族史及高血压病程均较PN、FSGS高;血尿发生率及血尿程度均低于另两组;蛋白定量亦低于PN、FSGS组,尤其与FSGS组比较差异有统计学意义;HN组左心室心肌重量指数（LVMI）明显高于PN、FSGS组,且与PN组差异有统计学意义（P〈0.05）.但BN组与上述两组相差不显著.BN组视网膜病变主要为0～Ⅱ级,占76%,而MN、FSGS则以Ⅲ～Ⅳ级病变为主.组织学显示PN组球性硬化的肾小球比率高于HN、FSGS组,小管慢性化指标PN组高于HN组,但无明显统计学意义.HN、BN组肌内膜细胞增殖、小动脉玻璃样变等血管病变较FSGS组明显,尤以BN组病变最显著.结论临床拟诊HN患者不能排除PN、FSGS.部分BN、MN与PN患者临床特征相似,单纯依据病史、化验等手段难以鉴别,肾组织病理检查是明确诊断的最佳手段.

Objective To investigate the clinical and pathological characteristics of patients with clinically presumed hypertensive nephrosclerosis （HN）. Methods Clinical data and renal biopsy results were obtained in 63 patients diagnosed clinically as HN （primary hypertension plus renal injury）. Results HN was confirmed by biopsy in 47 out of 63 patients （74. 6%, 12 malignant nephrosclerosis and 35 benign nephrosclerosis）. Primary nephritis （PN） was diagnosed by biopsy in 10 patients （7 IgA nephropathy, 2 mesangial proliferative nephritis, 1 chronic interstitial nephritis） and focal and segmental glomerulosclerosis （FSGS） in 6 patients. Blood pressure, body mass index, GFR and blood lipids were similar among groups. HN patients were related to higher age, more frequent family history of hypertension, longer hypertension duration, higher left ventricular mass index, lower serum creatinine and lower incidence of microscopic hematuria. Most patients with malignant nephrosclerosis and FSGS patients showed grades Ⅲ and Ⅳ retinopathy. Conclusion Our results show that HN was misdiagnosed in nearly 25% patients in this cohort. Since the clinical features are similar between HN, PN and FSGS, renal biopsy is needed to establish the diagnosis of HN.