影响类风湿关节炎X线平片进展的临床多因素分析

Muiti-variate analysis related to radiological progression in rheumatoid arthritis

目的探讨影响类风湿关节炎X线平片进展的几个临床因素，及评价其治疗价值。方法178例活动期类风湿性关节炎患者，内科治疗前后均接受X线平片检查，按照初诊时X线平片关节损害表现分为轻度（1组）、中度（2组）和重度（3组）。随访两年，评价放射学进展、临床缓解率和美国健康评定调查表（HAQ）等指标，并分析其相关性。结果以X线平片结果为指标，1组和2组之间进展率差异无统计学意义（P〉0．05）；3组（30．O％，9／30）分别和1组（15．4％，12／78）及2组（11．9％，7／59）之间进展率差异有统计学意义（P〈0．05），提示初诊时轻、中度关节损害患者应用药物遏制病变放射学发展概率均等，而重度关节损害患者放射学恶化更显著。所有患者治疗2年后临床缓解率为85．0％（142／167），3组之间差异无统计学意义（P〉0．05），提示关节损伤程度对临床缓解无显著影响，初诊时关节损伤严重者亦能达到较理想的临床缓解效果。结论女性、血类风湿因子阳性、HAQ评分较高、有关节外表现是类风湿关节炎放射学进展的高危因素。早期（〈6月）使用抗风湿药物有助于改善放射学进展。X线平片能确诊、复查和确定关节破坏程度，临床症状改善缓解者关节破坏不一定停止，须定时复查关节X线片，确定关节损伤进展程度来调整用药方案。

Objective To investigate the clinical factors related to radiological progression in rheumatoid arthritis （RA） and the role of radiology in the assessment of RA outcomes. Methods A total of 178 cases of active rheumatic arthritis were enrolled in a 2-year trial given radiological assessment at baseline and during follow up. These cases were classified into three groups, namely groups 1, 2 and 3 for mild, moderate and severe based on baseline X-ray images of joint damage. Radiological progression, clinical remission and Health Assessment Questionnaire （HAQ） were used in the two-year follow-up and analyzed for the correlation between each other. Results At the end point, groups 1 and 2 did not differ in radiologieal progression（P〉0.05）. Significant difference was found between group 1 （15.4%, 12/78）and group 2（30.0%, 9130） （P〈0.05） , as well as between group 3 （11.9% , 7159） and group 3 （P〈0.05） , suggesting that radiological damages may deteriorate more in patients with higher level of hone erosion at baseline. After 2 years of medications, the rate of clinical remission in all the cases was 85.0% （142/167） and was not different among the three groups （P〉0.05） , which indicated that clinical remission had no relevance with radiological progression. Conclusion Female gender, positive rheumatoid factor, high HAQ scores and peri- articular lesions are risk factors for radiological progression in RA. EarLy use of disease-modifying antirheumatie drugs （within less than 6 months） is benefieial fi^r patients with radiological progression. X-ray is sufficiently effective to confirm, re-evaluate and determine the articular erosion. Clinical remission may not necessarily indicate suspension of radiologieal progression and routine X-ray is required in the whole follow up process of RA in order to modify medications based on progression of artieular lesions.