逆转狼疮性肾炎肾功能不全的治疗决策分析

Appraisal of renal failure reversing therapies in lupus nephritis

目的 分析和探讨药物治疗对逆转狼疮性肾炎 (LN)肾功能不全的作用。方法 对1991～ 1999年住院的LN伴初发肾功能不全患者 173例进行 2 8周的回顾性队列研究。研究因素包括使用激素、环磷酰胺 (CTX)和环孢素。其中激素分为口服泼尼松、静脉注射氟美松和甲基泼尼松龙冲击 3个治疗等级 ;使用CTX分为未用、小剂量 (平均每周≤ 0 2 5g/m2 )和大剂量 (平均每周 >0 2 5g/m2 ) 3个等级 ;环孢素则采用是否应用 2种状态。运用COX回归分层分析的方法 ,分析这些治疗对肾功能恢复的影响。同时引入性别 ,年龄 ,病程 ,症状 ,并发症 ,狼疮活动指数 ,各种常规、生化和免疫学检查等 5 1项指标 ,建立COX比例危险率回归模型 ,并分别分析COX模型中有意义的各个临床和实验室指标对药物诱导肾功能恢复的影响。结果 142例 (82 1% )完成随访 ;93例 (6 5 5 % )肾功能恢复 ,17例 (12 0 % )死亡。COX回归分层分析显示 ,只有CTX治疗可影响肾功能的恢复。运用COX回归的多因素分析 ,校正混杂因素影响后 ,仍然显示CTX冲击治疗可以逆转LN的肾功能不全 ,其中小剂量CTX治疗对肾功能恢复的相关比 (RR)为 4 41,95 %的可信区间 (CI)为 1 0 3～ 18 94;大剂量CTX治疗的RR为 13 2 9,95 %CI为 3 11～ 5 6 82。性别 ,肾功能不全的病程 ,肾?

Objective This study aimed to explore the therapies of reversing renal failure in lupus nephritis. Methods The research strategy was a retrospective cohort study. 173 patients were included in the study. All of them were consecutive in patients of newly diagnosed renal failure (serum creatinine >180 μmol/L) with lupus nephritis from 1991 to 1999 in the university hospital. The research factors included steroids, cyclophosphamide and cyclosporin. Steroids were divided to oral prednisone, intravenous dexamethasone and intravenous methylprednisolone pulse; cyclophosphamide dose intensity was divided into three grades: none, low dose (average dose ≤0.25 g/m 2 body surface area per week) and high dose (average dose >0.25 g/m 2 body surface area per week). 51 demographic, clinical and laboratory data were included in the study as possible confounding factors. The study end point was recovery of renal function that was defined as a level of serum creatinine ≤116 μmol/L in the azotemia patients or a 50% reduction of serum creatinine and discontinuation of dialysis in the uremic patients. The improvement had to be maintained for at least three months. Collection of the study factors and outcome variable was conducted by two separate, blinded groups of clinical specialists with two structured abstracting forms. Results The number of complete following up patients was 142 (82.1%). After over 6 months of following up, 93 cases (65.5%) recovered their renal function and 17 cases (12.0%) died. In COX proportional hazard regression model, cyclophosphamide therapy was significantly associated with the recovery of renal function. The adjusted hazard ratio (HR) to recovery of renal function was 4. 41, 95% CI =1.03～18 94 in low dose; and the HR was 13.29, 95% CI =3.11～56.82 in high dose cyclophosphamide therapy. The gender, duration of renal dysfunction, small renal size, severe anemia and serum creatinine were also significantly associated with renal function recovery. Cyclosphosphamide therapy was not significantly associated with death. The variables associated with death were low level of serum albumin and edema. Conclusion Cyclophosphamids pulse was an efficient therapy in reversing renal failure of lupus nephritis, especially in the patients with short duration of renal failure, non small in renal size, and non severe anemia.