45例原发性膜性肾病治疗的探讨

Immunosuppressive and non-immunosuppressive treatments in patients with idiopathic membranous nephropathy

目的 :通过 45例原发性膜性肾病 (IMN)患者的治疗随访 ,探讨IMN的治疗。 方法 :Ⅰ组 :2 4h尿蛋白≤ 5g的肾病综合征 (NS)患者 12例 ,采用血管紧张素转换酶抑制剂 (ACEI) +抗血小板粘附剂和 (或 )抗凝治疗。Ⅱ组 :2 4h尿蛋白 >5g的患者 33例 ,采用糖皮质激素 (激素 ) +免疫抑制剂治疗 ,其中 :ⅡA组 (2 6 / 33)糖皮质激素 +环磷酰胺冲击治疗。ⅡB组 (7/ 33)Ponticelli方案 :激素与瘤可宁交替治疗 ,共 6个月。 结果 :Ⅰ组平均随访 32 6(7～ 6 0 )个月 ,6 7%患者缓解 (完全 +部分缓解 ) ,33%未缓解 ,无一例出现肾功能不全。ⅡA组平均随访 2 8 1(6～74)个月 ,5 8%出现缓解 (部分或完全 ) ,42 %未缓解 ,其中慢性肾功能不全 2例 (一例死于心衰与肺部感染 )。ⅡB组随访 36 (2 4～ 48)个月 ,6 7%缓解 (完全 +部分缓解 ) ,33%未缓解。 结论 :2 4h尿蛋白≤ 5g的NS患者或有NS倾向者 ,可不用激素 +免疫抑制剂治疗 ,仅用ACEI+抗血小板粘附剂或 (和 )抗凝治疗 ,有 6 7%的缓解。 2 4h尿蛋白 >5g的NS患者 ,需用激素 +免疫抑制剂治疗 ,兼以抗血小板粘附或 (和 )抗凝治疗 ,免疫抑制剂CTX和瘤可宁均有效 ,二者无明显差异。

Objective:The practice of treatment of idiopathic membranous nephropathy had been controversial over the past two decades practising,with various protocols applied in clincal settings.In this study,we reported our experience with immunosuppressive treatment in heavy proteinuric nephrotic IMN patients and non immunosuppressive treatment in the relatively less heavy proteinuric nephrotic IMN patients. Methodology:45 IMN patients were included in this study.Among them 12 patients(Group I)had a 24 hour urinary protein excretion(UPE)below 5 gram and received angiotensin converting enzyme inhibitor(ACEI)plus anti platelet adhesion treatment(APAT).26 patients(Group ⅡA)having a 24 hour UPE above 5 gram received oral prednison(1mg/kg·d -1 )plus cyclophosphomide pulse therapy(0 5～0 7 g/m 2 body surface intermittently),in addition to ACEI and APAT.And another 7 patients(Group ⅡB)having an hour UPE above 5 gram received methylpredisolone(0 5 g/d for 3 consecutive days)followed by oral prednison(0 5 mg/kg·d -1 )for the 1st,3rd and 5th month and plus oral chlorambucil(0 1～0 2 mg/kg·d -1 )for the 2nd,4th and the 6th month thereafter,besides ACEI and APAT. Results:After a mean period of 32 6 months′ follow up,50% of the patients in Group Ⅰ experienced complete remission,17% partial remission and 33% without remission but showing stable renal function.After a mean period of 28 1 months′ follow up,31% of the patients in Group ⅡA experienced complete remission,27% partial remission and 42% without remission in this group including 2 patients(7 6%)developed chronic azotemia.In Group ⅡB,4 patients(67%)obtained complete remission and 2 without remission and 1 patient dropped out for chlorambucil side effects.No significant difference in total remission rate was found among the three groups of IMN patients. Conclusion:For IMN patients whose 24 hour UPE being less than 5g,ACEI and APAT could bring a comparable remission rate without any sever side effect of the treatment.For cases whose 24 hour UPE being above 5g,steroids and cytotoxic agents might increase the remission rate and improve the prognosis.