肾组织IgG和C3沉积与糖尿病肾病预后的关联

Significance of IgG and C3 deposit in patients with diabetic nephropathy

目的:回顾性分析糖尿病肾病(DN)患者肾组织IgG及C3沉积与临床表现及预后的相关性。方法:选取2003年至2013年在南京军区南京总医院肾脏科行肾活检明确诊断DN的患者共460例,观察肾组织IgG和C3沉积情况与预后的相关性。结果:(1)按IgG沉积分为IgG(+)和IgG(-)组。IgG(+)组糖尿病病程更长、尿蛋白更多,平均动脉压、血清肌酐、糖化血红蛋白更高,雷公藤多苷治疗、视网膜病变率及外周神经病变率更高,血清白蛋白、血钙、估算的肾小球滤过率(e GFR)更低(P<0.05)。IgG(+)组的肾小管萎缩与间质纤维化、间质炎症程度、动脉硬化程度明显高于IgG(-)组(P<0.05)。按C3沉积分为C3(+)和C3(-)组:C3(+)组糖尿病及肾脏病病程较长,平均动脉压、血清肌酐、尿蛋白定量、视网膜病变率均较高(P<0.05)。(2)5年肾脏生存率50.8%,IgG(-)和IgG(+)组分别为60%和36.4%(P<0.01);C3(-)和C3(+)分别为53.5%和43%(P<0.01)。(3)单因素回归分析显示糖尿病病程、视网膜病变、平均动脉压、尿蛋白、血红蛋白、血清白蛋白、血清肌酐、糖化血红蛋白、肾小球分级、肾小管萎缩与间质纤维化(IFTA)、间质炎症、肾组织IgG和C3沉积对预后均有显著影响。多因素回归分析校正临床及病理相关因素后,糖化血红蛋白、总胆固醇、尿蛋白、血清肌酐、IFTA及视网膜病变是影响预后的独立风险因素,结论:DN患者肾组织IgG阳性或补体C3阳性者临床表现更重,预后更差,但IgG或C3沉积均不是肾脏预后不佳的独立危险因素。

Objective： To retrospectively analyze the association of linear IgG and C3 deposition with renal prognosis in patients with diabetic nephropathy. Methodology： Four hundred sixty patients with diabetes underwent renal biopsy and diagnosed with diabetic nephropathy according to the classification of Tervaert et al.（ glomerular classes Ⅰ toⅢ） from 2003 to 2013 were enrolled in this study. According to kidney immunofluorescent IgG and C3 staining,they were divided into IgG（ ＋）（ n = 165）,Ig A（-）（ n = 295） group and C3（ ＋）（ n = 114）,C3（-）（ n = 346） group.Results：（ 1） No significant differences were found in age,sex,body mass index（ BMI）,haemoglobin,duration of kidney injury between IgG（ ＋） and IgG（-） patients. However,IgG（ ＋） patients suffered longer duration of diabetes,heavier urinary protein,diabetic peripheral neuropathy and diabetic retinopathy,higher levels of serum creatinine,mean arterial blood pressure,glycosylated hemoglobin,lower levels of serum albumin,serum calcium and e-GFR（ P〈0. 05）.Interstisitial fibrosis,tubular atrophy（ IFTA）,interstitial inflamation and arteriosclerosis were more significant in IgG（ ＋） group（ P〈0. 05）. While C3（ ＋） patients also had longer duration of diabetes and kidney involvement,higher levels of mean arterial blood,serum creatinine,higher prevalence of diabetic retinopathy and urinary protein（ P〈0. 05）.（ 2） In all patients,with a 5-year renal survival rate was 50. 8%,which it was 60% to 36. 4% in IgG（ ＋） and IgG（-）group,53. 5% to 43% in C3（ ＋） and C3（-） group.（ 3） Cox proportional hazards regression analysis showed that duration of diabetes,prevalence of diabetic retinopathy,mean arterial blood pressure,urinary protein,haemoglobin,serum albumin,serum creatinine,glycosylated hemoglobin,degree of glomerular injury,IFTA,interstitial inflammation,kidney IgG deposition and C3 deposition significantly influence renal survival. But after adjustment for important clinical and pathological factors,total cholesterol,glycosylated hemoglobin,urinary protein,serum creatinine,IFTA and retinopathy were the independent risk factors of renal survival. Conclusion： The clinical manifestations and renal prognosis were worse in DN patients with renal IgG or C3 deposition,but neither of them was the independent risk factor of renal prognosis.