合并肾脏病变的类风湿关节炎临床表现分析

Clinical study of kidney damage with rheumatoid arthritis

[目的]探讨类风湿性关节炎(RA)中肾脏受累患者临床特点。[方法]回顾性分析2006—2008年RA合并肾脏病变(肾病组)患者35例及同期住院的未合并肾损害且无重要合并症的89例RA患者(非肾病组)的临床资料,比较两组的临床资料包括首发症状、病程中临床特点、化验室检查以及肾脏组织活检等情况。[结果](1)肾脏病变组首发症状以发热乏力者多于非肾脏病变组(P<0.05);在病程中肾脏病变组关节肿痛总数较非肾病组多见(P<0.05);两组患者入院时的ESR、CRP、WBC、IgG、IgM、IgA以及RF分别为(85±32)mm/h和(75±36)mm/h;(59±34)mg/L和(48±25)mg/L;(10.3±2.9)×109/L和(9.3±3.0)×109/L;(11.1±3.0)g/L和(10±2.1)g/L;(2.1±1.00)g/L和(1.6±0.98)g/L;(32±2.10)g/L和(29±0.98)g/L;(35±15)U/mL和(41±21)U/mL,两组中除ESR、WBC和IgG以及RF以外,IgM、IgA以及CRP比较差异有显著性意义(P<0.05)。(2)肾病组在停用疑似对肾脏有损害药物或使用肾毒性小的药物治疗2个月后分别有5例血尿8例蛋白尿患者转阴,与非肾脏病组相比差异无显著性意义(P>0.05);肾病组24 h尿蛋白治疗前后分别为(2.54±0.56)g/24 h和(1.63±0.21)g/24 h,两组比较差异有显著性意义(P<0.05)。肾病组ESR、CRP、WBC、IgM、IgA在治疗前后相比差异有显著性意义(P<0.05)。(3)选取其中5例持续性肾损害患者肾组织活检发现,2例系膜增生性肾小球肾炎,1例膜性肾病,1例新月体肾炎,1例膜增生性肾炎。[结论]合并肾脏病变的RA患者在首发症状和病程中的临床表现与未合并肾脏病变RA患者有所不同;肾脏病变者大多有用药史,临床肾脏损害以药物性和免疫炎症引起为主,排除药物因素后诊断不明者应尽早行肾穿刺明确病理诊断。

[Objective] To investigate the features of renal lesion in patients with rheumatoid arthritis.[Methods] To select the 35 patients with rheumatoid arthritis and 89 RA Patients without complications as control group form 2006-2008 in inpatient in hospital and prospective study the clinical data including the first symptoms,the course of the clinical features,laboratory tests and kidney biopsy.[Results]（1） Fever and fatigue as the first symptom had a higher incidence in patient with renal lesion than in patient with non-renal lesion.Compared with RA patients without renal injury,the number of painful and swollen in RA patients with renal injury were significantly higher（P〈0.05）.Two groups of patients with ESR,CRP,WBC,IgG,IgM,IgA and the RF were（85±32） mm/h and（75±36） mm/h;（59±34）mg/L and（48±25）mg/L;（10.3±2.9）×109/L and（9.3±3.0）×109/L;（11.1±3.0）g/L and（10±2.1） g/L;（2.1±1.00）g/L and（1.6±0.98）g/L;（32±2.10）g/L and（29±0.98）g/L;（35±15）U/mL and（41±21） U/mL,respectively,before treatment.In patients with renal injury,the level of CRP,IgM and IgA were higher than those in RA patients without renal injury（P〈0.05）.（2）Five hematuria and eight proteinuria patients changed negative 2 months after therapy,24 h urine protein level after treatment was significant decreased than those before treatment in RA patients with renal injury（P〈0.05）,ESR,CRP,WBC,IgM,IgA in Nephropathy group compared before and after treatment,the difference was statistically significant（P〈0.05）.（3）Kidney biopsy in five patients found two cases of mesangial proliferative glomerulonephritis,one case of membranous nephropathy,one cases of crescentic glomerulonephritis,one case of membrano-proliferative glomerulonephritis.[Conclusion] Difference in clinical feature and the first symptoms were found in RA patient with or without renal lesion.Kidney injury is mediated by an immunological inflammation and by nephrotoxic effects of numerous drugs usually used in rheumatoid arthritis treatment.Suspected causal drug should be removed from the treatment.Renal biopsy should be performed if necessary.