IgA肾病间质纤维化程度与临床指标及组织病理分型相关性分析

Correlation of renal interstitial fibrosis degree with the clinical indicators and pathological classification in patients with IgA nephropathy

目的探讨IgA肾病肾间质纤维化程度与临床指标及组织病理分型的相关性。方法 IgA肾病患者213例,根据组织病理牛津分型分为轻度肾间质纤维化组(间质纤维化≤25%)患者134例,中度肾间质纤维化组(间质纤维化>25%~50%)患者38例,重度肾间质纤维化组(间质纤维化>50%)患者41例。比较3组临床和肾脏组织病理学资料,采用ROC曲线分析估算肾小球滤过率对肾间质纤维化的预测作用,采用多因素logistic回归分析IgA肾病患者肾间质纤维化的影响因素,采用Spearman分析肾脏组织病理分型与IgA肾病肾间质纤维化程度的相关性。结果重度肾间质纤维化组24h尿蛋白定量、收缩压、舒张压、尿酸水平、24h尿蛋白定量≥3.5g发生率高于轻度肾间质纤维化组和中度肾间质纤维化组,中度肾间质纤维化组高于轻度肾间质纤维化组(P<0.05);重度肾间质纤维化组总胆固醇、估算肾小球滤过率、低密度脂蛋白胆固醇水平低于轻度肾间质纤维化组和中度肾间质纤维化组,中度肾间质纤维化组低于轻度肾间质纤维化组(P<0.05);估算肾小球滤过率预测肾脏间质纤维化的AUC为0.910±0.023(95%CI:0.865~0.955,P<0.001);重度肾间质纤维化组慢性肾脏病分期3、4、5期发生率(48.8%、26.8%、12.2%)和IgA+IgM+C3沉积比率(46.3%)高于中度肾间质纤维化组(15.8%、0、5.3%、39.5%)和轻度肾间质纤维化组(11.2%、0、0、17.9%),中度肾间质纤维化组高于轻度肾间质纤维化组(P<0.05):估算肾小球滤过率降低和24h尿蛋白定量增高是发生肾间质纤维化的独立危险因素(OR=1.957,95%CI:0.944~1.969,P<0.001;OR=2.255,95%CI:1.595~3.189,P<0.001),低密度脂蛋白胆固醇、收缩压、舒张压、尿酸、总胆固醇等指标对肾间质纤维化水平无明显影响(P>0.05);系膜细胞增生(r=0.386,P<0.001)、内皮细胞增生(r=0.300,P<0.001)、24h尿蛋白定量(r=0.348,P<0.001)、慢性肾脏病分期(r=0.567,P<0.001)与IgA肾病肾间质纤维化程度呈正相关,肾小球囊粘连、血管壁增厚与肾脏间质纤维化程度无明显相关性(P>0.05)。结论 IgA肾病肾间质纤维化程度与24h尿蛋白定量、估算肾小球滤过率及系膜细胞增生、内皮细胞增生存在相关性,通过估算肾小球滤过率可判断肾间质纤维化程度,改善临床指标可改善IgA肾病患者的预后。

Objective To explore the correlation of the degree of renal interstitial fibrosis with the clinical indicators and pathological classification in patients with IgA nephropathy.Methods Totally 213 patients with IgA nephropathy were divided into 134 patients with mild renal interstitial fibrosis（fibrosis degree≤25%）（mild group）,38 patients with moderate renal interstitial fibrosis（fibrosis degree〉25%-50%）（moderate group）,and 41 patients with severe renal interstitial fibrosis（fibrosis degree〉50%）（severe group）according to the Oxford Histopathologic Classification.The clinical and pathological data were compared among three groups.The role of the estimated glomerular filtration rate（eGFR）in predicting renal interstitial fibrosis was analyzed by ROC,the influencing l factors for renal interstitial fibrosis were analyzed by multivariable logistic regression analysis,and correlation of renal pathological classification with renal interstitial fibrosis degree was analyzed by Spearman method.Results In severe group,24 hurine protein quantitation,systolic blood pressure,diastolic blood pressure,uric acid level and 24 hurine protein≥ 3.5 g were significantly higher than those in mild group and moderate group（P〈0.05）,and in moderate group than those in mild group（P〈0.05）.The levels of total cholesterol,eGFR and low-density lipoprotein cholesterol（LDL-C）were significantly lower in severe group than those in mild group and moderate group,and in moderate group than those in mild group（P〈0.05）.The AUCof eGFR for predicting renal interstitial fibrosis was 0.910±0.023（95%CI：0.865-0.955,P〈0.001）.The incidences of chronic kidney disease（CKD）stage 3,4 and 5（48.8%,26.8%,12.2%）and IgA＋IgM＋C3 deposition ratio（46.3%）in severe group were significantly higher than those in moderate group（15.8%,0,5.3%,39.5%）and mild group（11.2%,0,0,17.9%）（P〈0.05）,and higher in moderate group than those in mild group（P〈0.05）.The low eGFR and high 24 hurine protein quantitation were the independent risk factors for renal interstitial fibrosis（OR=1.957,95%CI：0.944-1.969,P〈0.001;OR=2.255,95%CI：1.595-3.189,P〈0.001）.LDL-C,systolic blood pressure,diastolic blood pressure,uric acid and total cholesterol had no significant influences on renal interstitial fibrosis（P〉0.05）.Mesangial cell proliferation（r=0.386,P〈0.386）,endothelial cell hyperplasia（r=0.300,P〈0.300）,24 hurine protein quantitation（r=0.348,P〈0.348）and CKD stage（r=0.567,〈P0.001）were positively correlated with renal interstitial fibrosis degree in patients with IgA nephropathy.Glomerular capsule adhesion and thickening of the blood vessel wall had no obvious correlation with renal interstitial fibrosis degree（P〉0.05）.Conclusion The renal interstitial fibrosis degree in patients with IgA nephropathy is correlated with the 24 hurine protein quantitation and eGFR,mesangial cell proliferation and endothelial cell proliferation.The eGFR can be used to evaluate the degree of renal interstitial fibrosis.To correct the clinical indexes can improve the prognosis of patients with IgA nephropathy.