糖皮质激素与非免疫抑制剂治疗原发性IgA肾病的Meta分析

Meta-analysis of Glucocorticoids and Non-immunosuppressor in ImmunoglobulinA Nephropathy

目的评价糖皮质激素与非免疫抑制剂治疗原发性IgA肾病的疗效和安全性。方法按照Cochrane系统评价协作网肾脏病组提供的检索策略,检索Cochrane图书馆、PubMed、中国期刊全文数据库(CNKI)、维普数据库(VIP)及中文生物医学文献数据库(CBM),手工检索相关文献,检索范围均从建库至2013-02-28,筛选有关糖皮质激素与非免疫抑制剂治疗原发性IgA肾病疗效和安全性的随机对照试验,试验组采用糖皮质激素(试验组A),或联合血管紧张素转换酶抑制剂(ACEI)或血管紧张素Ⅱ受体拮抗剂(ARBs)(试验组B),对照组采用安慰剂或空白对照或抗血小板药物(对照组A),或ACEI或ARBs(对照组B)。由3位评价员进行资料提取和质量评价,应用RevMan5.0软件包进行Meta分析。结果最终纳入13篇符合条件的文献,均为英文文献,文献质量等级均为B级;共包括818例原发性IgA肾病患者,其中试验组396例,对照组422例。Meta分析结果示:(1)试验组A患者终末期肾病(ESRD)〔OR=0.29,95%CI(0.15,0.57),P=0.0002〕、肌酐倍增〔OR=0.29,95%CI(0.18,0.47),P<0.00001〕发生率均低于对照组A,缓解率〔OR=25.00,95%CI(1.29,483.99),P=0.03〕、肾小球滤过率〔WMD=17.87,95%CI(4.93,30.82),P=0.007〕及胃部不适〔OR=4.89,95%CI(1.51,15.86),P=0.008〕、食欲增加〔OR=5.60,95%CI(1.91,16.40),P=0.002〕发生率均高于对照组A,24 h尿蛋白定量少于对照组A〔SMD=-0.49,95%CI(-0.67,-0.30),P<0.00001〕,而两组患者血清肌酐水平间差异无统计学意义〔WMD=-23.98,95%CI(-53.93,5.96),P<0.00001〕。(2)试验组B患者ESRD〔OR=0.14,95%CI(0.02,0.80),P=0.03〕、肌酐倍增〔OR=0.11,95%CI(0.03,0.40),P=0.0007〕发生率均低于对照组B,24 h尿蛋白定量少于对照组B〔WMD=-0.53,95%CI(-0.89,-0.17),P=0.004〕,而两组患者缓解率间差异无统计学意义〔OR=1.78,95%CI(0.90,3.51),P=0.10〕。结论现有证据显示,糖皮质激素可以降低原发性IgA肾病患者ESRD、肌酐倍增发生率,减少蛋白尿,提高缓解率及肾小球滤过率,但应注意胃部不适及食欲增加等不良反应;糖皮质激素联合ACEI或ARBs能更有效地保护原发性IgA肾病患者肾功能,减少蛋白尿,改善患者预后。

Objective To assess the efficacy and safety of glucocorticoids and non - immunosuppressive in primary immunoglobulinA （IgA） nephropathy. Methods This study searched Cochrane library, PubMed, CBMdisc, CNKI, VIP, CBM, from the beginning of the databases to February 28, 2013, for randomized controlled trials of glucocorticoids and non - immunosuppressor in treatment of primary IgA nephropathy. Test group were given glucocorticoids （group T - A）, or combined with angiotensin converting enzyme inhibitor （ACEI） or angiotensin IT receptor antagonist （ARBs） （group T - B）; the control group given placebo or blank control or antiplatelet drug （group C - A）, or ACEI or ARBs （group C - B）. Three reviewers drew data and evaluated the quality. RevMan 5. 0 software was used to carry out Meta - analysis. Results Thirteen literatures were included and all were in English, their quality was grade B; a total of 818 patients with primary IgA nephropathy were included, 396 in test group, 422 in control group. By Meta - analysis, the incidences of end - stage renal diseases （ESRD） [OR=0.29, 95%CI （0.15, 0.57）, P=0.0002], creatinine （Cr） doubling [OR=0.29, 95%CI （0.18,0.47）, P〈 0.00001] were lower in group T - A than in group C - A, remission rate [OR = 25. 00, 95% CI （1. 29, 483.99）, P = 0.03], glomerular filtration rate [WMD = 17. 87, 95% CI （4.93, 30.82）, P = 0. 007], incidences of stomach discomfort [OR = 4.89, 95% CI （1. 51, 15.86） P = 0. 008] and increased food appetite higher, 24 h urine protein quantitation less [OR = 5.60, 95% CI （1. 91, 16.40）, P = 0.002], there was no significant difference in serum Cr between 2 groups [WMD = -23.98, 95%CI （ -53.93, 5.96）, P 〈0. 00001]. The incidences of ESRD [OR =0.14, 95%CI （0.02, 0.80）, P = 0.03], Cr doubling [OR = 0. 11, 95% CI （0.03, 0.40）, P = 0. 0007] were lower in group T - B than in group C- B, 24 h urine protein quantitation less [WMD = - 0. 53, 95% CI （ - 0. 89, - 0. 17）, P = 0. 004], but there was no significant difference in remission rate between 2 groups [OR = 1. 78, 95% CI （0.90, 3.51）, P = 0. 10]. Conclusion Glucocorticoids can reduce the incidences of ESRD and Cr doubling, proteinuria, and improve remission rate and glomerular filtration rate in patients with primary IgA nephropathy, but probably with adverse reactions such stomach discomfort, increased appetite and so on. Glucocorticoids combined with ACEI or ARBs are more effective in protecting renal function, reducing proteinuria and improving patients＇ prognosis.