吗替麦考酚酯诱导治疗弥漫增生性狼疮性肾炎的临床疗效

Induction therapy with mycophenolate mofetil vs cyclophosphamide for patients with class Ⅳ lupus nephritis

目的:比较吗替麦考酚酯(MMF)和间断静脉环磷酰胺(IV-CTX)诱导治疗伴新月体形成的弥漫增生性狼疮性肾炎(LN)的疗效。方法:80例经肾活检明确诊断的弥漫增生性LN(Ⅳ型LN)且伴新月体(≥15%)形成的患者,接受激素联合MMF诱导治疗(MMF组,n=39)或IV-CTX冲击治疗(IV-CTX组,n=41),回顾性分析两组诱导治疗6月的缓解率[总缓解率和完全缓解(CR)率]。结果:MMF组和IV-CTX组基线临床病理数据无显著差异,中位新月体比例分别为34.6%和31.0%(P=0.836)。MMF组6月总缓解率显著高于IV-CTX组(92.3%vs 73.1%,P=0.024),其中CR率亦高于IV-CTX组,但无统计学差异(48.7%vs 34.1%,P=0.186)。在新月体比例<50%的LN(n=61)患者中,MMF组6月总缓解率(96.7%vs 74.2%,P=0.026)显著高于IV-CTX组,其中CR率高于IV-CTX组(46.7%vs 35.5%,P=0.375)。新月体比例≥50%LN患者(n=19)中MMF组6月总缓解率和CR率虽高于IV-CTX组,但无统计学差异。MMF组补体C3恢复正常比例显著高于IV-CTX组(64.1%vs 35.9%,P=0.013)。结论:MMF治疗伴新月体形成的Ⅳ型LN的诱导缓解率高于IV-CTX冲击治疗,但仍需前瞻性随机对照研究的证实。

Objective： To compare the induction efficacy of mycophenolate mofetil （MMF） and intravenous cyclophosphamide （IV-CTX） in class IV lupus nephritis （LN） patients with ≥15% crescents. Methodology：From 2000 to 2009, the clinical and histological data of all patients with LN in our center was reviewed in this retrospective analysis. Among them, eighty patients biopsy-proven class IV LN with crescent formation in ≥ 15% of glomeruli were investigated. According to the induction regimens, they were divided into MMF group （n = 39） and IV-CTX group （n = 41 ）. Results：There were no differences in baseline clinical and pathological parameters between the two groups. The median ratio of crescents in MMF and IV-CTX group was 34. 6% and 31.0% respectively （P = 0. 836）. The 6-month remission rate was 92. 3% in MMF group, significantly higher than that in IV-CTX group （73. 1% ,P=0. 024）, while the complete remission （CR） rates of 48.7% in MMF and 34. 1% in IV-CTX group respectively were no significant difference （P=0. 186）. In patients with 〈50% crescents （n=61）, MMF group achieved a much higher remission rates（96.7 % vs 74. 2%,P=0. 026）and CR（46. 7% vs 35.5%, P= 0. 375） than IV-CTX group. In patients with i〉50% crescents （n= 19）, remission rates and CR were also higher in MMF group than in IV-CTX group, but without statistical significance. The ratio of patients with normalization of complement C3 after 6-mo induction therapy was significantly higher in MMF group than in IV-CTX group（64. 1% vs 35.9% ,P=0. 013）. Conclusion：Compared to intravenous CTX, MMF had more favorable induction efficacy in class IV LN with ≥ 15% crescents. The difference of two induction regimen in LN with different degree of crescent formation needs large samples, and randomized controlled trail.