中等量蛋白尿IgA肾病的免疫抑制治疗探讨

Discussion of immunosuppressive therapy formoderate proteinuria IgA nephropathy

目的通过回顾性分析中等量蛋白尿IgA肾病患者的随访资料,探讨中等量蛋白尿IgA肾病的治疗方法。方法分析肾活检确诊且随访时间>80个月的156例中等量蛋白尿(2.0~3.5 g/d)IgA肾病患者临床资料,依据是否使用激素、免疫抑制剂,分为A组(58例)和B组(98例),以需要肾脏替代治疗或死亡或达80月为随访终点,比较尿蛋白定量与eGFR随时间的变化,用Kaplan-Meier法分析肾脏生存率,探讨激素、免疫抑制对肾脏存活的影响。结果 A组58例,B组98例.基线临床及病理特征相似。两组均给予ARB药物治疗,研究期间A组10例因高血压、高血糖、感染等停止激素、免疫抑制剂治疗,5例因低血压、肾功能恶化停止ARB药物治疗,但继续随访。B组反复低血压、肾功能恶化5例停止ARB药物治疗,但均继续随访。在使用激素等治疗6月后A组尿蛋白从基线(2.84±0.44)g/d显著减少至(1.59±0.71)g/d,eGFR从基线(72.93±24.66)mL/min/1.73m2增加至(81.90±18.44)mL/min/1.73 m2,但在治疗随访18月以后直至随访结束尿蛋白量、eGFR在A、B两组中无差异。在随访结束时A组80月肾脏存活率79.31%,B组73.47%。Kaplan-Meier曲线A组95%置信区间68.45~76.66,B组95%置信区间为66.70~74.39,经Log-rank检验两组肾脏存活无差异(P=0.833)。结论 AR B能降低蛋白尿,延缓肾功能恶化的IgA肾病,对中等量蛋白尿的IgA肾病患者使用免疫抑制治疗早期可以减少蛋白尿、改善eGFR,但中后期肾脏存活并无显著差异,选择免疫抑制治疗时是否不能单纯依靠尿蛋白定量、是否需要参考肾脏病理的活动指标有待进一步研究证实。

Objective Through retrospective analysis of middle-grade albuminuria patients with IgA nephropathy follow-up data to explore the treatment of moderate proteinuria IgA nephropathy. Methods The clinical data of 156 cases of IgA nephropathy with moderate proteinuria（2.0~3.5 g/d） diagnosed by renal biopsy and followed up for 80 months were divided into the group A（58 cases）and the group B（n = 98）. Kidney replacement therapy or death was required or 80-month follow-up endpoint was used to compare urinary protein quantitation with eGFR over time. Kaplan-Meier method was used to analyze renal survival and to explore the impact on kidney survival of hormones and immunosuppression. Results A group of 58 cases, B group 98 cases. The baseline clinical and pathological features were similar. ARB treatment was given to both groups. During the study period, 10 patients in the group A were stopped by steroid and immunosuppressive drugs such as high blood pressure, hyperglycemia, infection, and 5 cases were stopped ARB drug treatment due to hypotension and renal dysfunction. The B group repeated hypotension, renal function deterioration in 5 cases stopped ARB drug treatment,but were followed up. Urinary protein in the group A decreased significantly from baseline（2.84 ± 0.44） g/d to（1.59 ± 0.71） g/d after 6 months of treatment with hormones and eGFR increased from baseline（72.93 ± 24.66） mL/min/1.73 m2 to（81.90 ± 18.44） mL/min/1.73 m2. However, there was no difference in eGFR between the A and the B groups after 18 months of follow-up until the end of follow-up. At the end of follow-up, the renal survival rate in the group A was 79.31% in 80 months and in the group B was 73.47%.Kaplan-Meier curve 95% confidence interval was 68.45 ~ 76.66 in the group A, and 95% confidence interval was 66.70 ~ 74.39 in the group B. No significant difference in survival was found between the two groups by Log-rank test（P = 0.833）. Conclusions ARB can reduce proteinuria and delay IgA nephropathy with deteriorating renal function. Immunosuppressive therapy can reduce proteinuria and improve eGFR in patients with IgA nephropathy with moderate proteinuria. However, there is no significant difference in the survival of kidney between middle and late stages. Immunosuppression treatment cannot simply rely on urinary protein, whether the need to refer to renal pathological activity indicators need further study confirmed.