他克莫司或环磷酰胺联合糖皮质激素治疗特发性膜性肾病的疗效比较

Efficacy of tacrolimus or cyclophosphamide combined with glucocorticoids in the treatment of idiopathic membranous nephropathy

目的比较他克莫司或环磷酰胺联合糖皮质激素治疗表现为肾病综合征的特发性膜性肾病(IMN)的疗效及安全性。方法选择2016年9月至2017年9月在山东省千佛山医院住院部或门诊收治,且已经肾穿刺活检、病理证实为IMN的患者46例,分为2组,分别给予他克莫司联合小剂量糖皮质激素(观察组,n=27)和环磷酰胺联合小剂量糖皮质激素(对照组,n=19)。治疗过程中观察并记录2组患者治疗前、治疗后4、8、12、24、36周的24h尿蛋白定量、血清白蛋白、血清肌酐、空腹血糖、总胆固醇水平、三酰甘油的变化,并评估治疗缓解率,比较2种治疗效果的差异。结果2组患者入组时一般资料(性别、年龄、病程)及入组前实验室指标差异均无显著性(P>0.05)。治疗过程中两组均未出现骨髓抑制等严重的不良反应,无中途退出实验人员。经过36周的治疗,观察组患者临床总缓解率(88.89%)高于对照组(78.95%),差异有统计学意义(P<0.05)。2组患者治疗后24h尿蛋白定量水平较治疗前有明显缓解(P<0.05),且观察组24h尿蛋白定量下降幅度明显高于对照组,差异有极显著性(P<0.01);两组患者治疗后血清白蛋白水平较治疗前也有显著升高,且观察组血清白蛋白水平上升幅度明显高于对照组,差异有统计学意义(P<0.01)。2组血清肌酐、血糖、三酰甘油、总胆固醇治疗前、后相比未见明显变化(P>0.05)。治疗过程中,2组患者均未出现骨髓抑制等严重不良反应。结论他克莫司联合糖皮质激素治疗IMN有效且安全性较好,与环磷酰胺比较,他克莫司能迅速缓解蛋白尿,缓解率优于环磷酰胺。

Objective To observe the clinical efficacy and safety of tacrolimus(TAC)or cyclophosphamide(CTX)combined with glucocorticoids in treatment of idiopathic membranous nephropathy.Methods A retrospective study was conducted on 46 patients who had been diagnosed as idiopathic membranous nephropathy from September 2016 to September 2017 in Qianfoshan Hospital of Shandong Province.The patients were followed up for 36 weeks.The patients were divided into two groups.Twenty-seven patients were given TAC combined with glucocorticoid as experimental group.The 24-h urinary protein,serum albumin,serum creatinine,fasting blood glucose,triglyceride,total cholesterol levels and the rate of remission were recorded before and 4,8,12,24,and 36 weeks after treatment.The difference in the efficacy between the two groups was compared.Results There were no significant differences in general data(gender,age,course of illness)and laboratory tests before treatment between the two groups(P>0.05).After 36 weeks of treatment,16 cases(59.25%)obtained complete remission in the experimental group and 7 cases(36.84%)in the control group.The complete remission rate in the experimental group was significantly higher than that in the control group(P<0.01).Eight cases(29.63%)in the experimental group,and 8 cases(42.11%)in the control group obtained partial remission.Three cases had ineffective efficacy in the experimental group(11.11%),and 4 cases(21.05%)in the control group.The 24-h urinary protein quantification was significantly reduced in the two groups after treatment as compared with that before treatment(P<0.05).The 24-h urinary protein quantification in the experimental group was decreased from(10.1±3.2)g to(1.2±2.6)g(P<0.01),and that in the control group was decreased from(8.6±3.8)g to(1.7±2.7)g(P<0.01),with the difference being very statistically significant.The serum albumin level was also significantly higher after treatment in both two group than that before treatment.The serum albumin level in the experimental group was increased from(22.3±3.6)g/L to(43.0±3.3)g/L(P<0.01),and from(23.5±4.5)g/L to(40.9±6.1)g/L in the control group(P<0.01),with the difference being statistically significant.There was no significant change in serum creatinine,blood glucose,triglyceride,total cholesterol during the treatment in both groups before and after treatment(P>0.05).During the course of treatment,no serious adverse reactions such as myelosuppression occurred in both groups.Conclusions TAC combined with glucocorticoid is effective and safe in the treatment of idiopathic membranous nephropathy.As compared with CTX,TAC can rapidly reduce 24-h urine protein quantification.