狼疮性肾炎患者并发股骨头坏死的临床特征及危险因素

Clinical characteristics and risk facters of avascular necrosis of the femoral head in patients with lupus nephritis

目的：回顾性分析狼疮性肾炎（LN）患者并发股骨头坏死的临床特征及其危险因素。方法：699例（女性607例，男性92例，平均年龄28.4±11.1岁）肾活检确诊的初治LN患者，根据是否发生股骨头坏死分为股骨头坏死组（n=41）和无股骨头坏死组（n=658）两组，回顾性分析股骨头坏死发生的流行病学及其临床特征，比较两组间临床和免疫学以及肾脏病理指标的差异，Logistic回归法分析并发股骨头坏死的危险因素。结果：41例（5.9%）LN患者在随访42～96月（中位时间58月）并发股骨头坏死，发生率男性（9.8%）高于女性（5.3%），病理类型中V＋III型最高（13%），其次为V型（8.6%）和III型（6.8%）。股骨头坏死在随访10～88月（中位时间35月）发生，78%股骨头坏死在1？4年内发生。临床症状分别为髋部疼痛29例（70.7%），髋部疼痛伴膝关节或下肢疼痛4例（7.8%），膝关节或下肢疼痛8例（19.5%）。股骨头坏死组雷诺征（24.4% vs 12.2%，P〈0.05）、口腔溃疡（19.5% vs 10.5%，P〈0.05）、贫血（63.4% vs 43.8%，P〈0.05）、血小板减少（29.3% vs 16%，P〈0.05）、血清抗心磷脂抗体阳性率（56.1% vs 38.8%，P〈0.05）和治疗未缓解率（17.1% vs 3.2%，P〈0.05）均显著高于无股骨头坏死组。多因素回归分析发现治疗未获缓解、贫血、抗心磷脂抗体阳性、肾脏病理有V型病变（V,V＋III/IV）（OR依次为6.28，P〈0.001；3.18，P=0.001；2.39，P=0.012；2.30，P=0.019）是LN并发股骨头坏死的独立危险因素。结论：狼疮性肾炎并发股骨头坏死在治疗1~4年内高发，部分症状不典型。治疗不能获得缓解、抗心磷脂抗体阳性及肾小球膜性病变是并发股骨头坏死的高危患者，对高危LN患者应在治疗10个月开始定期行影像学检查以早期诊断股骨头坏死。

Objective： To analyze the clinical characteristics and risk factors of avascular necrosis of the femoral head （ANFH） patients with lupus nephritis （LN）. Methodology： Six hundred ninety nine initial-treatment patients with LN （607 females, and 92 males with a mean age of 28.4±11.1 years old） were divided into ANFH group （n=41） and non-ANFH group （n=658）. The epidemiological and clinical features of ANFH were investigated and the clinical, immunological and pathological differences were compared between the two groups. Univariate analysis and multiple logistic regression analysis were applied for associated impact factors. Results： The incidence of ANFH were 5.9% during the following 58 months （42-96 months）, witch was higher in males （9.8%） than in females （5.3%）. ANFH could be observed in patients with type V＋III commonly （13%）, and next were in patients with type V（8.6%） and type III （6.8%）. ANFH was diagnosed during 10 to 88 with a median time of 35 months after treatment, and 78% patients were diagnosed in 4 years. The clinical symptoms of ANFH included hip pain （70.7%）, hip pain associated with knee or leg pain （7.8%）, and knee or leg pain （19.5%）. Compared with non-ANFH group, the patients with ANFH group had higher incidence of Raynaud’s sign（24.4% vs 12.2%, P〈0.05）, oral ulcer（19.5% vs 10.5%, P〈0.05）, anemia（63.4% vs 43.8%, P〈0.05）, thromcytopenia（29.3% vs 16%, P〈0.05）, ACL positivity（56.1% vs38.8%, P〈0.05）, and non-remission（17.1% vs 3.2%,P〈0.05）. Multiple factor logistic regression analysis revealed that non-remission （OR 6.28, P〈0.001）, anemia（OR 3.18, P=0.001）, ACL positivity （OR 2.39,P=0.012）, and membranous lesion in renal biopsy （OR 2.30,P=0.019） were independent risk factors for ANFH patients with LN. Conclutions： The incidence of ANFH was high in patients with LN after making diagnosis of 1~4 years. Some patients were delayed to diagnose of ANFH for its atypical symptoms. The patients who had no remission for treatment, membranous lesion in renal biopsy and ACL positivity were high risk group of ANFH, and should do MRI test of the hip joint routinely when the time of treatment for 10 months.