狼疮性肾炎小管间质病理改变的临床意义

The clinical significance of tubulointerstital lesions in patients with active lupus nephritis

目的探讨狼疮性肾炎（ＬＮ）中肾小管间质病变（ＴＩＬ）病理分级与临床的关系。方法按照ＴＩＬ的评分标准对６５例活动性ＬＮ患者肾活检组织进行分级并结合临床资料进行分析。结果ＴＩＬ０级占２３１％，以ＷＨＯⅠ、Ⅱａ型为主；１级占２７７％，可有Ⅱ～Ⅵ型；２～３级各占２４６％，均以Ⅳ型为主。ＴＩＬ０级者尿Ｎ乙酰βＤ氨基葡萄糖胺酶与β２微球蛋白（β２ＭＧ）水平均高于正常；与０级比较，１～３级尿蛋白量较多，低补体血症发生率较高，尿Ｌｙｓ与β２ＭＧ水平也较高；与０～１级比较，２～３级表现为年龄较大，病程较长，尿渗量明显降低，治疗有效率较低；与０～２级比较，３级血抗ｄｓＤＮＡ阳性率较低，复发率较高；随着ＴＩＬ分级升高，高血压的发生率与肾活检时血肌酐水平也逐渐升高。此外，１～２级血尿的发生率较高。结论活动性ＬＮ中ＴＩＬ发生率高，小管功能改变较早，发生率相对更高。小管间质病变分级对ＬＮ肾小球病理、临床表现、治疗。

Objective To investigate the correlation between the degree of tubulointerstitial lesions (TIL) and the clinical manifestations, tubular dysfunction, response to treatment or probability of relapse in patients with lupus nephritis (LN). Methods A retrospective study was performed. Sixty five renal biopsies from active LN patients were classied as grade 0～3 according to the degree of TIL. Results The prevalence of absence of obvious TIL (Grade 0), predominantly detected in WHO class Ⅰ and Ⅱa, was 23.1% by light microscope. The patients with TIL Grade 1 accounted for 27.7% and had WHO class Ⅱ～Ⅵ. Grade 2 and 3, mostly found in WHO class Ⅳ, accounted for 24.6%, each. The patients with signficant TIL (Grade 1～3), as compared to those with Grade 0, had abnormal levels of urinary NAG and β 2 microglobulin, increased amount of urinary protein excretion, higher prevalence of hypocomplementemia, higher urinary lysome and much higher β 2 microglobulin. The patients with Grade 2 and Grade 3 tended to have older average age, longer course of the disease and lower urinary osmolarity than those who had Grade 1 TIL. They also had relatively worse response to treatment. The patients with Grade 3 had higher relapse incidence and lower positive rate of anti dsDNA antibody. Serum creatinine level at the time of renal biopsy and prevanlence of hypertention became higher and higher as the degree of TIL proceeded. In addition, the patients with Grade 1～2 had higher prevalence of hematuria than those with Grade 0 or 3. Conclusion TIL is a frequent finding in active LN. Tubular dysfunction occurs quite frequendtly and early. The degree of TIL is probably an indicator of clinical manifestations for LN patients. It is of help not only in the choice of treatment, but also in the prediction of relapse occurrence of this disease.