双重滤过血浆置换联合免疫抑制剂治疗对重度活动性类风湿关节炎患者磁共振成像的影响

Magnetic resonance imaging outcomes of double filtration plasmapheresis combined with immunosuppressive agents in patients with high active rheumatoid arthritis

目的探讨双重滤过血浆置换（DFPP）联合免疫抑制剂（来氟米特＋甲氨蝶呤）治疗对重度活动性类风湿关节炎（RA）患者磁共振成像（MRI）的影响。方法纳入58例RA患者，病程6个月至12年，采用计算机自动生成的随机号，将患者随机分为治疗组和对照组。对照组予以来氟米特10mg，每日2次，甲氨蝶呤15mg，每周1次；治疗组在对照组治疗的基础上予以DFPP治疗3～4次，每次间隔7～14d。随访至6个月。通过右腕关节MRI平扫加增强观察基线和治疗1、6个月时滑膜炎、关节腔积液及骨髓水肿的变化，应用RA磁共振评分标准（RAMRIS）判断对MRI滑膜炎的影响。组内比较采用配对t检验，组间比较采用独立样本t检验。结果治疗组6个月时滑膜、血管翳、骨髓水肿计分分别为（1．4±1．6）、（0．13±0．35）、（5±4），显著低于对照组[分别为（7．9±1．3）、（2．76±0．43）、（16±12），P均〈0．01]；治疗组30例（100％）关节腔积液均消失，对照组无一例消失（P〈0．01）。治疗组达到MRI滑膜炎完全缓解（滑膜、血管翳无强化，关节腔无积液）＋疾病活动指数（DAS）28缓解标准的为16例（53％），对照组无一例达到此标准（P〈0．01）。1个月时治疗组DAS28、健康评估问卷（HAQ）分别由（7．5±1．0）、（2．23±0．58）下降至（3．5±1．2）、（0．50±0．73），差异有统计学意义（P〈0．01）；MRI影像滑膜、血管翳、关节腔积液、骨髓水肿无明显变化（P〉0．05）。结论DFPP联合免疫抑制剂治疗对重度活动性RAMRI滑膜炎症有明显缓解作用。MRI对疾病活动的判断及治疗方案的选择可作为必要的手段之一。

Objective To evaluate the efficacy of double filtration plasmapheresis （DFPP） combined with immunosuppressive agents （leflunomide plus methotrexate） on synovitis in magnetic resonance imaging （MRI） in patients with high active rheumatoid arthritis （RA）. Methods Fifty eight patients with RA （disease duration 6 months to 12 years） were randomly divided. Thirty-one were randomized to the treatment group and 27 were randomized to the control group. All patients received leflunomide 10 mg, two times daily; plus methotrexate 15 mg orally once weekly. DFPP was performed in the treatment group once 1-2 weeks for 3-4 sessions. Control patients did not receive DFPP. All patients underwent contrast-enhanced MRI of the right wrist at the baseline and 6 months, 1 month in the treatment group. The signs including synovitis pannus, bone marrow edema and effusion were observed on MRI. The scoring of synovial hypertrophy, pannus, bone marrow edema were measured according to the outcome measures in RA MRI scoring system. Comparisons between groups were performed with paired-samples t test and independent-sample t test. Results The MRI synovitis score, MR1 pannus score and MRI bone marrow edema in the treatment group was （1.4±1.6）, （0.13± 0.35 ） and （5±4） respectively, so was significantly lower than that of the control group [ respectively for （7.9± 1.3）, （2.76±0.43）, （16±12）, P〈0.01]. 53% of the treatment group satisfied both the disease activity score 28-joint assessment and MRI synovitis assessment （no enhancement of synovium or pannus, no effusion）, but none in the control group （P〈0.01）. Significant changes at 1 month was observed in DAS28 and HAQ scores （P〈0.01）, but not in the MRI synovitis score, MRI pannus score, MRI bone marrow edema score and effusion in the treatment group （P〉0.05）. Conclusion DFPP combined with immunosuppressive agents can significantly improve synovitis in MRI in patients with high active RA. Improvement of the signs of MRI is later than that in the clinic. So imaging assessment may be necessary for accurate evaluation of disease status and selection of therapy.