肾病综合征合并血栓栓塞症临床特点分析

Clinical characteristics in nephrotic syndrome with thromboembolic complications

目的:回顾性分析肾病综合征(NS)不同肾脏病理类型合并血栓栓塞症患者临床表现和实验室检查特点。方法:42例NS合并血栓栓塞症患者均行肾活检明确诊断,其病理类型包括微小病变(MCD)9例(21.4%)、局灶节段性肾小球硬化(FSGS)10例(23.8%)和膜性肾病(MN)23例(54.8%)。分析患者发生血栓栓塞症时的临床表现,血液和尿液等实验室检查特点。血栓栓塞症的确诊方法为:肾血管、下腔静脉、肺动脉以及腹部其他血管行CT血管成像(CTA);四肢深静脉、颈内静脉采用压迫型超声;磁共振血管成像(MRA)检查头颅血管。结果:(1)本组患者年龄9岁～65岁,三组患者平均年龄、性别分布无统计学差异,MN组平均年龄(36.2±17.0)岁,较文献报道特发性MN患者平均年龄水平低(P<0.05)。(2)NS病程中的任何阶段均可发生血栓栓塞症,MCD组多见于NS复发阶段,MN组多为NS治疗无效者。(3)全身深静脉均可发生血栓,常见部位:肾静脉血栓(RVT)21处、肺动脉栓塞(PE)15处和下腔静脉10处;90.5%RVT和60%PE患者为MN组;MN组平均每例发生血栓部位数(1.87处)显著高于MCD(1.1处)和FSGS(1.1处)。(4)镜下或肉眼血尿、腰痛和肾脏体积增大为RVT患者的常见临床症状;PE患者主要临床症状为胸痛、呼吸困难和咯血;少数患者为无症状性VTE。(5)实验室检查结果提示MN组血白蛋白高于MCD和FSGS组,而胆固醇、血红蛋白水平,血小板数量和红细胞压积均低于MCD和FSGS组;MCD和FSGS组抗凝血酶III值降低尤其明显(均低于MN组)。D二聚体阳性率86.5%。结论:NS合并血栓栓塞症十分常见,不同病理类型,其发生血栓的时间、部位和实验室检查特点有所不同,少数患者发生VTE可无临床症状,高危患者D二聚体阴性亦不能排除血栓可能,需进一步筛查。

Objective：To study the clinical and laboratory features of thromboembolic complications in the adult patients in different pathological types with nephrotic syndrome. Methodology：Forty-two biopsy-proven adult nephrotic syndrome patients with thromboembolic complications were enrolled in this retrospective study. According to their pathological types three groups were divided. They were 9 （21.4%） cases of minimal change disease （ MCD）, 10 （23.8%） cases of focal segemental glomerulosclerosis （FSGS） , and 23 （54. 8% ） cases of membranous nephrosis （MN）. The iconography method of diagnosis of thrombus： puhnonary artery, venae cavae, renal vessels by computer tomography angiography （CTA） ; limb vessels by compression ultrasonography; and magnetic resonance angiography （MRA） for the central nervous system vessels. Results： （ 1 ） The age was from 9 to 65 years old. There was no difference between the age and gender in these three groups. The mean age in MN was（36. 2 ± 17.0）years old, which was lower than the data from the literature （ P 〈 0. 05 ）. （2） The thromboembolic complications could appear any time of the NS duration, it most likely happened in relapse phage of MCD, but the resistant NS in MN was very common. （ 3 ） The most common vessels＇ sites of thrombus were renal vein （21 cases）, pulmonary artery （ 15 cases） and venae cavae （ 10 cases）. 90. 5% patients with RVT and 60% patients with PE were from MN. Every MN patients had average 1.87 sites of thrombus, which was significant higher than MCD （1.1） and FSGS （1.1）. （4） Microscopic or gross hematuria, lumbodynia, and increased kidney volume were the most common clinical symptoms in RVT. The frequent symptoms in PE were chest pain, dyspnea, and hemoptysis, but few patients were asymptomatic. （5）In patients with MN, the serum albumin were higher than that in MCD and FSGS, but the cholesterol, hemoglobin, haematocrit, and platelets were lower than that MCD and FSGS. The plasma AT-III levels of MCD and FSGS were lower than that of MN （ P value were both less than 0. 05 ）. The positive rate of D-Dimer was 86. 5%. Conclusion：The thromboembolic complications in patients with NS are very frequent. The embolic duration, site and labora- tory data were various in different nephrotic syndrome pathological types. Few patients were asymptomatic with thrombus. Although the D-Dimer is the sensitive marker, it should not neglect the thrombus for the negative result.