两种改良Ponticelli方案治疗特发性膜性肾病的远期疗效分析

The long-term therapeutic effects of two ponticelli methods in the treatment of idiopathic membranous nephropathy

目的 关注比较每日口服CTX累计或每月静点CTⅨ冲击两种方案的疗效、复发率、不良反应.方法 选取肾活体组织检查经光镜及电镜确诊为IMN的患者共88例,CTX口服组40例,CTX冲击组48例.①CTX口服组：口服环磷酰胺100 mg/d,累积剂量8—10 g;②CTX冲击组：CTX静滴0.8～1.0 g,每月冲击1次,连用6次,后每3个月1次,累积剂量8～10g.两组所有患者使用泼尼松起始剂量为0.8 ～1.0 mg·（kg·d）-1,于服药后第8～12周逐渐减量.结果 治疗3个月时比较,CTX口服组完全缓解率显著高于CTX冲击组（10％和6％,P＜0.05）.两组缓解高峰均在治疗后第12个月时（CTX冲击组83％,CTX口服组80％）.CTX口服组的失访率、复发率及白细胞降低等副反应均显著高于CTX冲击组（P＜0.05）.结论 虽然CTX口服组早期缓解率高于冲击组,但两组长期疗效无明显差异;无论CTX口服累计或静脉冲击联合糖皮质激素对IMN患者均有效.此外,口服组并发症发生、复发率及患者失访率均高于CTX冲击组,提示CTX冲击治疗较口服治疗更为合理.而对于药物的远期疗效、复发,仍需进一步长期随访观察.

Objective To investigate the long-term clinical effects of two ponticelli methods in the treatment of idiopathic membranous nephropathy.Methods All 88 patients of idiopathic membranous nephropathy were divided into two groups according to different methods.One group（n =40） received oral therapy of CTX（100 mg/d,cumulative dose 8 ～ 10 g）,and another group（n =40） were treated with monthly intravenous therapy of CTX（0.8 ～ 1.0 mg/d,cumulative dose 8 ～ 10 g）.All patients received treatment of metacortandracin,which was gradually reduced during 8 ～ 12 weeks.At the end of study,the clinical remission rate,complication rate,recurrence rate and lost rate were evaluated in two groups.Results Compared with the oral CTX group,the clinical remission rate was decreased for 3 months in intravenous CTX group （10% vs.6%,P 〈 0.05）,and the peak value of remission rate was 12 months.The side-effect of recurrence rate,lost rate and low white blood cell count in oral group were higher than intravenous CTX group （P 〈 0.05）.Conclusions The early clinical remission rate is better in oral group,however,there is no difference on the long-term clinical effect between two groups.In a word,the combination of CTX and metacortandracin is for IMN patients.Moreover,compared with the intravenous CTX group,the complication rate,recurrence rate and lost rate are higher than oral CTX group.The therapy of oral CTX may be more security,however,more studies of long-term observation are needed to make the evidence stronger.