吗替麦考酚酯治疗寡免疫复合物型新月体肾炎的疗效观察

Effects of mycophenolate mofetil on patients with pauci-immune crescentic glomerulonephritis.

的比较吗替麦考酚酯（MMF）与环磷酰胺（CTX）间断静脉冲击疗法治疗寡免疫复合物型新月体肾炎（PICGN）的临床疗效。方法将1999年6月至2005年9月在南京解放军肾脏病研究所住院经临床病理确诊的44例PICGN患者分为两组，甲基泼尼松龙静脉冲击后，分别接受MMF（MMF组22例）或CTX间断静脉冲击（CTX组22例）联合激素治疗。MMF剂量1．5g/d或2．0g／a；CTX剂量为0．5～0．75g／m^2，每月静脉滴注1次，6个月后改为每3个月1次。所有患者随访时间6个月或以上。比较两组治疗的临床疗效和副反应。结果治疗12个月时两组总显效率分别为90．9％和72．7％，差异无统计学意义，MMF组完全显效率（59．1％）显著高于CTX组（27．3％），MMF组13例抗中性粒细胞抗体（ANCA）阳性患者中有3例（23．1％）ANCA转阴，CTX组12例AN．CA阳性患者均未转阴。随访中，MMF组1例（4．5％）复发，复发率显著低于CTX组（5例，22．7％）。MMF组5例（22．7％）发生感染，其中3例为严重肺部感染，CTX组1例（4．5％）发生肺部感染。MMF组治疗初期接受替代治疗的5例（22．7％）患者中，随访12个月时4例摆脱替代治疗；CTX组治疗初期接受肾脏替代治疗的7例（31．8％）患者中，随访12个月时5例摆脱替代治疗。治疗初期未接受替代治疗的患者中，MMF组1例（4．5％）在随访7个月时进入终末期肾病（ESRD），CTX组有4例（23．5％）分别在随访第12—72个月时进入ESRD。MMF组2例患者死于巨细胞病毒肺炎，CTX组2例患者死亡，1例死于细菌性肺炎，1例死于意外。MMF组预测5年肾存活率（81．3％）高于CTX组预测5年肾存活率（51．3％），但差异无统计学意义。结论与传统CTX疗法比较，MMF治疗PICGN诱导显效率更高，改善肾功能作用明显，复发率低，肾存活时间长。

Objective To compare the effect, relapse rate and outcomes between mycophenolate mofetil（MMF） and pulse intravenous cyclophosphamide （CTX）in the induction therapy of pauci-immune crescentic glomendonephritis （PICGN）in Chinese. Methods A total of 44 patients who bad PICGN [ 16 male, 28 female, age （ 46. 8 ± 13.7 ） y ], of whom 25 patients were ANCA positive ,were enrolled in this study. All patients had renal involvement with 〉150% crescent formation prior to the study and received either MMF treatment（ MMF group, n = 22）or intermittent CTX pulse therapy（ CTX group, n = 22）. The patients in both groups also received methylprednisolone（MP） pulse therapy followed by oral prednisone. General conditions, clinicopathological findings, remission rate, relapse rate, and outcomes were compared. All the patients were followed up until June 2005, with an average follow-up of 8 N 60 （ Med 27） months in the MMF group, and 6 - 72 （ Med 29） months in the CTX group. Results No significant difference was found between MMF group and CTX group in general conditions,base parameters of clinical and pathological findings. The remission rate at the 12th month in MMF and CTX group was 90. 9% and 72.7% respectively. The complete remission rate in MMF group（59. 1% ） was significantly higher than that of the CTX group（27.3% ） （P 〈0. 05）. Furthermore,3 of the 13 ANCA positive patients（23.7% ）in the MMF group and none of the 12 patients in the CTX group were ANCA negative after 12 months＇ treatment. The relapse rate in MMF group（4.5%） was lower than that of the CTX group（23.5% ）. Four patients（ 18. 2% ） in the CTX group and 1 （4. 5% ）in the MMF group entered into end stage renal failure（ESRF） during the follow-up. Two patients died in each group. However,the side effect of infection was more significant in the MMF group（22. 7% ）than in the CTX group （4. 5% ）. Conclusion MMF is more effective than intermittent CTX pulse therapy in inducing remission, improving renal function and reducing relapse rate in patients with PICGN, although potentially associated with a higher infection rate.