高血压肾损害的临床病理特点及预后

Clinico-pathological characteristics and outcome of patients with biopsy- proven hypertensive nephrosclerosis

目的：探讨行肾活检的高血压肾损害（HN）患者的临床、病理特点及长期预后,比较良性肾动脉硬化（BN）及恶性肾动脉硬化（MN）组患者的临床病理特征. 方法：选取2003年1月至2012年12月在南京军区南京总医院肾脏科经临床及肾活检明确诊断的HN患者179例,回顾性分析其临床病理特点,探讨影响肾脏预后的危险因素. 结果：HN患者平均年龄（43.8±11.2）岁,本组患者以男性为主（82％）,肾活检时中位高血压病程5.0年,最高收缩压及舒张压分别为（196.5±35.9） mmHg和（127.8±25.6） mmHg,中位血清肌酐（SCr） 144.1μmol/L,中位估算的肾小球滤过率（eGFR） 47.1 ml/（min·1.73m2）,中位蛋白尿0.8 #24h.BN和MN的比例分别为54.7％及45.3％.MN组患者与BN组患者相比,高血压病程短、平均血压水平高,SCr及尿酸高、蛋白尿多,贫血较严重,靶器官损害（眼底、心脏）发生率高,且终末期肾脏病（ESRD）的发生率高.本组HN患者肾活检后随访时间0.3～10.8年,中位时间为2.9年,33例（18.4％）患者进入ESRD,5年和10年累积肾存活率分别为82.6％、38.4％.肾活检时eGFR下降、蛋白尿水平上升、动脉的恶性病变、肾小球硬化比例高是HN患者进展至ESRD的独立危险因素. 结论：HN患者肾活检时eGFR、蛋白尿量,动脉恶性病变、肾小球硬化比例等对肾脏预后具有独立预测价值;MN和BN组患者临床、病理表现及预后明显差异.

Objective： To investigate the renal outcome and its predictors in patients with biopsy-proven hypertensive nephrosclerosis （HN） , and to compare the ciinico-pathological characteristics and prognoses of benign nephrosclerosis （BN） and malignant nephrosclerosis （MN）. Methodology： One hundred seventy nine patients with biopsy- proven HN in Nanjing Jinling Hospital were enrolled in this retrospective study. According to the renal histological examination, they were divided into two groups： benign nephrosclerosis （HN, n = 98）, and malignant nephrosclerosis （MN, n = 81 ）. Their renal survival and the relationships between clinical and pathological parameters and outcome were assessed and compared. Results：They were male gender predominant （ 147 cases, 82%）. At biopsy, the mean age was 43. 8 years, the median duration of hypertension was 5.0 years, the mean systolic blood pressure （SBP） and diastolic blood pressure （DBP） was （ 196. 5±35.9） mmHg and （127.8±25.6） mmHg, the median serum creatinine （SCr） and eGFR were 144. 1 μmol/L and 47. 1 ml/min/1.73m2, and median proteinuria was 0. 77 g/24h. At biopsy, benign nephroselerosis （BN） was found in 54. 7% and malignant nephrosclerosis （MN） was 45.3%. Compared with BN, the patients with MN were younger; they had higher levels of SCr, uric acid and proteinuria, and lower levels of hemoglobin; they also had a higher incidence of hypertensive heart disease and hypertensive retinopathy, and worse renal outcome. During a median follow-up of 2. 9 years, 33 cases （18.4%） reached ESRD, and the 5- and 10-year cumulative renal survival after biopsy, as calculated by K-M methods, were 82. 6 and 38.4%. A decreased baseline eGFR, increased proteinuria, the presence of MN and an increased percentage of global sclerosis （GS） were the independent predictors of future ESRD. Conclusion ：The renal outcome of HN patients was independently associated with the baseline eGFR and proteinuria, presence of MN and percentage of GS. The clinico-pathological characteristics and prognoses were of significant difference between patients with MN and BN.