不同亚型狼疮性肾炎患者临床病理特征和预后的比较

Clinicopathological features and long-term renal outcomes in lupus nephritis patients with different pathological classification

目的:比较Ⅲ型与Ⅲ+Ⅴ型、Ⅳ型与Ⅳ+Ⅴ型及Ⅳ-S亚型与Ⅳ-G亚型狼疮性肾炎(LN)患者的临床病理特点和肾脏远期预后。方法:收集南京军区南京总医院肾脏科肾脏病登记系统中经肾活检明确诊断为增生型LN、随访时间≥1年的汉族成年患者肾活检时的临床和病理资料。观察终点为终末期肾病(ESRD)。病理分型参照ISN/RPS 2003病理分型方案。结果:Ⅲ型LN患者10年和20年肾脏生存率分别为92.1%和72.2%,Ⅲ+Ⅴ型分别为91.5%和88.9%,Ⅳ型分别为82.7%和60.3%(其中Ⅳ-S亚型分别为86.2%和69.6%;Ⅳ-G亚型分别为81.9%和58.9%),Ⅳ+Ⅴ型分别为82.7%和54.7%。Ⅲ+Ⅴ型和Ⅳ+Ⅴ型LN患者尿蛋白分别重于Ⅲ型和Ⅳ型患者;病理上慢性化病变分别重于Ⅲ型和Ⅳ型患者;急性病变分别轻于Ⅲ型和Ⅳ型患者。Ⅳ-S亚型LN患者抗中性粒细胞胞质抗体阳性率高于Ⅳ-G亚型患者;高血压、蛋白尿、低补体血症轻于Ⅳ-G亚型患者;病理上节段性袢坏死和新月体重于Ⅳ-G亚型患者;白金耳、毛细血管内增生轻于Ⅳ-G亚型患者。结论:Ⅲ型与Ⅲ+Ⅴ型、Ⅳ型与Ⅳ+Ⅴ型、Ⅳ-S亚型与Ⅳ-G亚型LN患者之间虽然临床病理特点不同,但肾脏生存率均无差异。

Objective：To observe the clinicopathological features and renal outcomes between class m and class Ⅲ ＋ V, class IV and class IV ＋ V, and subclass IV-S and IV-G of patients with lupus nephritis. Methodology： The records of all adult patients with biopsy-proven class Ⅲ, class Ⅲ ＋ V, class IV and class IV ＋ V lupus nephritis in the Nanjing Glomerulonephritis Registry followed for at least one year were reviewed. All patients were pathologically classified according to the 2003 International Society of Nephrology/Renal Pathological Society （ISN/RPS） classification system. Results： The levels of proteinuria and histological chronic lesions were severe, while the histological acute lesions were mild in patients with class Ⅲ＋ V and IV ＋ V was severe than those in patients with simple class Ⅲ and IV. The rate of serum ANCA was higher, while the degree of hypertension, proteinuria and hypocomplementemia were lower in patients with class IV-S than those in patients with IV-G. The histological lesions of segmental necrosis and crescentic formation were severe, while the lesions of platinum loop and endocapillary proliferation were mild in patients with class IV-S than those in patients with IV-G The 10- and 20-year renal survival rates of LN patients with class Ⅲ were 92. 1% and 72. 2%; with class Ⅲ ＋ V, 91.5% and 88.9%; with class IV, 82. 7% and 60. 3% （with subclass IV-S, 86. 2% and 69. 6%; with subclass IV-G, 81.9% and 58.9%） ; with class IV ＋ V, 82. 7% and 54. 7% ; with ＇class V, 96. 8% and 83.8%. Conclusion： Proliferative lesions combined with membranous lesions presented with both clinicopathological characteristics of the two types of lesions, but their renal outcomes were not different from proliferative lesions alone. Subclass IV-S and IV-G had their own characteristics respectively, but the division of class IV into the two subclasses was not meaningful for predicting renal outcomes.