中国特发性膜性肾病患者长期预后及危险因素分析

Long-term outcome and prognositc factors of indiopathic membranous nephropathy in Chinese population

目的:特发性膜性肾病(IMN)是成人肾病综合症最常见的病因之一,其病程进展缓慢。虽然普遍认为IMN患者在亚洲人群的预后相对良好,但目前尚无中国大规模IMN患者长期预后的分析资料。方法:由南京军区南京总医院全军肾脏病研究所MN数据库中提取自1990至2005年间肾活检患者,并排除继发性及合并其他影响预后因素,选取随访时间>2年的IMN患者,进行临床及病理指标与预后相关性分析。结果:总计217例IMN患者入选,活检时年龄19～83岁,男性占58.5%。肾活检后5年、10年及15年肾生存率分别为96.8%,93.0%及85.5%。生存分析显示,活检时有血压升高(P<0.05)以及血肌酐升高(>109.6μmol/L,P<0.01)的患者预后较差。单因素Cox回归分析显示:临床指标中高血压,年龄>50岁及活检时即有血肌酐升高均为患者终末期肾功能衰竭(ESRF)的高危因素;病理指标中肾小管间质慢性病变重为ESRF的高危因素。多因素Cox回归分析显示活检时肾功能衰竭以及肾小管间质慢性病变重为IMN患者ESRF的独立危险因素。依患者蛋白尿转归不同进行分组,作生存分析显示尿蛋白持续不缓解患者ESRF风险明显增高,而尿蛋白部分缓解与完全缓解的患者之间预后无明显差异。结论:IMN在中国人群中预后相对良好,活检时即出现肾功能不全以及病理上肾小管间质慢性化病变分级较高为IMN患者出现ESRF的独立危险因素。治疗后出现尿蛋白缓解的患者预后相对较好。

Objective：To investigate the prognosis and risk factors in Chinese patients with idiopathic membranous nephropathy （IMN） retrospectively. Methodology：All patients were admitted to Nanjing Institution of Nephrology from January 1990 to December 2005 with biopsy proven IMN, and at least 24 months feUow-up in this retrospective chart review. Their clinical features and pathologic changes were collected. Results：A total of 217 patients were enrolled in the study. The age was ranged from 19 to 83 years old, with male ratio 58.5%. The overall renal survival rate was 96. 8% , 93.0% and 85.5% at 5, 10 and 15 years after renal biopsy, respectively. When the clinical and pathologic features at the time of biopsy were evaluated, the patients with hypertension （P = 0. 012） and elevated serum creatinine （SCr, defined as SCr 〉 109.6 μmol/l,P 〈0. 001 ） had worse prognosis. Cox univariate analysis showed that hypertension, age 〉50 years and elevated SCr were clinical risk factors, and tubulointestinal chronic change stage （ defined as fibrosis area percentage of cortical tubulointestinal tissue, every 25 percent as a stage, HR = 3. 627, P 〈 0. 001 ） was pathological risk factor for ESRF. Cox multivariate analysis showed that elevated Ser and tubulointestinal chronic change stages were independent risk factors for ESRF. Conclusion：IMN is a renal disease with a comparatively good prognosis in Chinese population, with renal survival rate more than 90% at 10 years after renal biopsy. The elevated SCr, and tubulointestinal chronic change is an independent risk factor of ESRF.