33例伴有肾组织乙肝病毒抗原沉积的肾炎患者临床和病理分析

Clinicopathological Analysis for Nephritis Accompanied by Hepatitis B Virus(HBV)Antigens Depositing in Glomeruli in 33 Cases

目的探讨血清乙肝病毒(HBV)标志物与肾组织HBV抗原沉积、肾脏病理改变之间的关系。了解乙肝病毒相关性肾炎(HBV-GN)的临床和病理特点。方法肾组织HBsAg和(或)HBcAg沉积的肾炎患者33例(沉积阳性组)。同时收集血清乙肝标志物阳性但肾组织中不伴HBsAg和(或)HBcAg沉积的肾炎患者29例为对照组(沉积阴性组)。两组均采用免疫组化检测肾活检组织中HBsAg和HBcAg。结果①两组患者在血压、血尿、蛋白尿程度及肾功能方面差异均无统计学意义。②沉积阳性组病理以不典型膜性肾病(MN,占66.7%)和IgA肾病(IgAN,占15.2%)为主。沉积阳性组免疫荧光IgG、补体Clq和纤维蛋白相关抗原(FRA)阳性率明显增高(均P<0.05)。沉积阳性组的肾小管间质病变远比沉积阴性组严重(P<0.01)。③病毒学检查发现,沉积阳性组血清e抗原阳性率较高(48.5%),而e抗体阳性率较低(18.2%),阴性组则相反;其中沉积阳性组HBV-DNA定量≥105copies/mL者占48.5%,沉积阴性组HBV-DNA定量≥105copies/mL者占13.8%,两组差异有统计学意义。④33例患者中6例血清HBV标志物阴性或仅有HBsAb阳性,血HBV-DNA病毒载量<103copies/mL的患者肾组织中检测到HBsAg和(或)HBcAg沉积,且免疫荧光显示免疫球蛋白和补体沉积满堂亮者6例(100%);光镜显示不典型MN 6例(100%)。结论对于成年人依据临床难作出HBV-GN的诊断。HBV-GN病理表现具有多样性,以不典型MN和IgAN为主。肾活检组织的免疫荧光大多数表现为满堂亮。肾组织HBV抗原沉积现象可以出现在血清HBV标志物阴性或仅HBsAb阳性的患者,提示应重视肾组织HBV抗原检测,尽可能降低HBV-GN的漏诊率,尤其是血清HBV标志物阴性的患者。

Objective To investigate clinicopathological features of HBV related glomerulonephritis（HBV-GN）,the deposition of HBV related antigens in glomeruli,and the association between serum markers of HBV and antigen deposition as well as the pathological manifestations.Methods Thirty-three patients with deposition of HBV related antigens in glomeruli were involved in this study（group A）.Twenty-nine cases without deposition of HBV related antigens served as group B.HBsAg and HBcAg were detected in the renal tissues by immunohistochemistry.Results There was no significant difference in blood pressure,hematuria,albuminuria and renal function between the two groups（P0.05）.In group A,the major renal pathological categories were atypical membranous changes（MN,66.7%）and IgA nephritis（IgAN,15.2%）.The positive rate of IgG,Clq and FRA staining was higher and the degree of the tubular interstitial lesions in group A was severer than in group B.Virology examination revealed that the positive rate of serum e antigen in group A was higher than in group B.In 16 cases（48.5%）of group A,the quantity of HBV-DNA was greater than 105copies/mL,and in 4 cases（13.8%）of group B,the quantity of HBV-DNA was greater than 105copies/mL with the difference being statistically significant between the two groups.In 6 cases negative for serum markers of HBV or only negative for HBsAb and blood HBV-DNA load was 103copies/mL,there was HBsAg and/or HBcAg deposition,immunofluorescence displayed ＂full-light＂ due to deposition of immunoglobulins and complement,and light microscopy showed atypical MN.Conclusion It is difficult for adults to diagnose HBV-GN according to clinical features.The pathological manifestations of adults HBV-GN are diversified,and the major are IgAN and atypical MN.Immunofluorescence analysis shows ＂full-light＂ in 70% of HBV-GN.There is HBV antigens deposition in glomeruli of patients negative for HBV markers or only HbsAb positive,suggesting the importance of renal tissue examinations for HBV antigens,especially those patients with negative blood HBV markers.