扁桃体切除对肾移植术后IgA肾病复发的影响

Clinical efficacy of tonsillectomy in renal transplant patients with recurrent IgA nephropathy

目的初步探讨扁桃体切除治疗肾移植术后复发性IgA肾病的临床效果。方法收集11例自2014年5月在华中科技大学同济医学院附属同济医院器官移植研究所行移植肾穿刺活检确诊IgA肾病复发的病例，行扁桃体切除治疗，中位随访14（4—38）个月，观察扁桃体切除前后的尿蛋白、尿红细胞、估算肾小球滤过率（eGFR）水平及血清总IgA水平变化，并统计该组病例扁桃体切除后的移植受者和移植。肾存活率。结果11例受者中，8例在扁桃体切除后蛋白尿显著减少甚至转阴，并在之后的随访期内保持良好。其余3例受者的扁桃体切除对缓解蛋白尿疗效不明显，最终移植肾均于继续随访1年内失功，患者恢复血透治疗。影响扁桃体切除治疗效果的因素可能包括：原发病为急进性肾小球肾炎合并新月体形成、二次移植IgA肾病复发、出现蛋白尿后干预时机过晚等。本组病例扁桃体切除后血清中IgA水平显著下降，切除后随访期间均无急性排斥反应或感染发生，11例受者全部存活，8例移植肾存活。结论扁桃体切除是移植肾复发性IgA。肾病比较可靠有效的治疗方式，可以在未来的临床中逐步推广应用，但需要注意进行干预的时机及原发IgA肾病的病理特点。

Objective To investigate the therapeutic efficacy of tonsillectomy for patients with recurrence of IgA nephropathy （IgAN） after kidney transplantation. Methods From May 2014, tonsillectomy was performed in 11 renal transplant patients with biopsy-proved recurrent IgAN. In a median follow-up of 14 （4 -38 ） months, data of proteinuria, hematuria, estimated glomerular filtration rate （eGFR）, and serum levels of IgA in these patients were compared before and after tonsillectomy. Patient＇s survival and renal graft survival were also summarized. Results A remission of proteinuria was observed in 8 patients after tonsillectomy, and this status maintained well in the subsequent follow-up. Three patients had no or minimal reduction of proteinuria after tonsillectomy and returned to dialysis within 1 year after tonsillectomy. Possible causes could be severe primary IgAN of crescentric glomerulonephritis, IgAN recurrence in kidney retransplantation, and late tonsillectomy after IgAN recurrence. Serum levels of IgA significant decreased and no patients developed acute rejection or infection after tonsillectomy. In the 1-year follow-up, no patients died and grafts survived well in 8 out of 11 patients. Conclusions Tonsillectomy may represent an effective and reliable way to treat recurrence IgAN after kidney transplantation, and may be applied widely in the future clinical management. However, early intervention is critical and effects may depend on the pathological features of primary IgAN.