特发性膜性肾病合理治疗方案的研究

A study of therapeutic strategies for idiopathic membranous nephropathy

目的比较特发性膜性肾病(idiopathic membranous nephropathy,IMN)各治疗方案的临床疗效,以探讨合理的治疗方案。方法回顾性分析我院76例IMN患者的临床病理资料和治疗方案,随访临床疗效。根据采用的治疗方案将76例患者分成4组,包括对症治疗组、单用糖皮质激素组(激素治疗组)、单用免疫抑制剂组(免疫抑制组)和糖皮质激素联合免疫抑制剂组(联合治疗组),比较各治疗方案的临床疗效。结果(1)对症治疗组患者的肾病综合征的发生率和24 h尿蛋白定量显著低于激素治疗组和联合治疗组患者。(2)对症治疗组、激素治疗组、免疫抑制组和联合治疗组患者的总缓解率分别为56.3%、73.7%、66.7%和78.9%。对症治疗组、激素治疗组和联合治疗组患者的总缓解率在总体上无统计学差异。IMN患者2年和5年肾脏存活率分别为89.2%和79.3%。(3)将激素治疗组和联合治疗组患者分成低危、中危和高危进行分析,发现对于低危和中危患者,激素治疗组和联合治疗组的缓解率无统计学差异,而对于高危患者,联合治疗组的缓解率显著高于激素治疗组。(4)将激素治疗组和联合治疗组患者分为缓解亚组和未缓解亚组,发现两亚组间仅有治疗前估算的肾小球滤过率有统计学差异,未缓解亚组显著低于缓解亚组。结论糖皮质激素和免疫抑制剂联合治疗存在高危因素的患者较单用激素治疗可明显地提高患者的蛋白尿缓解率。治疗前患者的肾小球滤过率是影响预后的重要因素。

Objective To compare the efficacy of different therapies for idiopathic membranous nephropathy （IMN） patients, and to discuss their rationality. Methods The clinicopathological data and therapies of 76 patients with IMN in our hospital was retrospectively analyzed and reviewed, and the efficacy was followed up. According to the different therapies, 76 patients were divided into 4 groups, including symptomatic treatment group, glucocorticoid-alone group, immunosuppressant-alone group, and glucocorticoid in combination with immunosuppressant group （combination group）. Comparison and analysis of the efficacy of the different therapies were made. Results （1） The incidence of nephrotic syndrome and 24-hour proteinuria of patients in symptomatic treatment group were significantly lower than those in glucocorticoid-alone group and combination group. （2） The remission rates of 4 groups were 56.3%,73.7%,66. 7%and 78.9%, respectively. In general, no statistical differences were observed in the remission rates of patients among the symptomatic treatment group, glucocorticoid-alone group and combination group. The 2-year and 5-year renal survival rates were 89. 2% and 79.3%, combination group were divided into low remission rate was observed between the respectively. （3） Patients in glucocorticoid-alone group and risk, moderate-risk and high-risk patients. No difference in two therapies for low-risk and moderate-risk patients. But for high-risk patients, the remission rate in combination group was significantly higher than that in glueoeorticoid-alone group. （4） Patients in glucocortieoid-alone group and combination group were divided into remission subgroup and non-remission subgroup. It showed that only estimated glomerular filtration rate （eGFR） between these two subgroups had statistical difference, and eGFR in non-remission subgroup was lower than that in the remission subgroup. Conclusions For high-risk patients,treatment with glucocortieoid combined with immunosuppressant may improve the remission rate of proteinuria significantly. Glomerular filtration rate before treatments is an important prognostic factor.