肾病水平蛋白尿的急性链球菌感染后肾小球肾炎患儿临床特点及预后分析

Analysis of Clinical Characteristics and Prognosis of Children with Glomerulonephritis after Acute Streptococcal Infection with Nephrotic Proteinuria

目的探讨肾病水平蛋白尿的急性链球菌感染后肾小球肾炎患儿的临床特点、病理及预后特点。方法回顾性分析西安市儿童医院2013年1月—2017年1月确诊为急性链球菌感染后肾小球肾炎、肾病水平蛋白尿并行肾穿刺活组织检查的21例患儿(肾病水平蛋白尿组)的诊治资料,选择同期80例非肾病水平蛋白尿患儿(非肾病水平蛋白尿组)的诊治资料,总结肾病水平蛋白尿组肾脏病理检查特点,对比分析两组患儿的临床资料、治疗情况及预后情况。结果肾病水平蛋白尿组患儿肾脏病理光镜检查显示均为毛细血管内增生性肾小球肾炎,9例(42.9%)有新月体形成,但比例均<10.0%;电镜检查显示上皮下"驼峰"样电子致密物沉积,其中1例电子致密物沉积较多。免疫荧光检查显示仅9例(42.9%)有C3沉积(≥++)而无IgG沉积,2例伴明显的IgG沉积(≥++)。肾病水平蛋白尿组肉眼血尿发生率、急性肾损伤(AKI)发生率高于非肾病水平蛋白尿组,清蛋白水平、抗链球菌溶血素"O"试验阳性率低于非肾病水平蛋白尿组(P<0.05)。肾病水平蛋白尿组患儿除了给予抗感染及对症治疗外,6例患儿给予糖皮质激素治疗,非肾病水平蛋白尿组均未使用激素治疗。肾病水平蛋白尿组肉眼血尿消失时间、水肿消退时间、尿蛋白转阴时间及补体恢复时间长于非肾病水平蛋白尿组(P<0.05)。结论肾病水平蛋白尿的急性链球菌感染后肾小球肾炎患儿AKI发生率更高,近期预后良好,仅少数遗留镜下血尿。

Objective To investigate the clinical characteristics,pathology and prognosis of children with glomerulonephritis after acute streptococcal infection with nephrotic proteinuria.Methods A retrospective analysis was conducted based on the treatment data of 21 patients(the nephrotic proteinuria group)who were diagnosed with glomerulonephritis after acute streptococcal infection with renal proteinuria and underwent renal biopsy from January 2013 to January 2017 in Xi'an Children's Hospital.In addition,the diagnostic,treatment and prognostic data of 80 non-nephrotic patients with proteinuria(the non-nephrotic proteinuria group)were obtained.The characteristics of renal pathological examination of the nephrotic proteinuria group were summarized,and the clinical data,treatment and prognosis of the two groups were analyzed and compared.Results Kidney pathological examination in the nephrotic proteinuria group showed that all patients had capillary endoproliferative glomerulonephritis.Nine cases(42.9%)had crescent body formation but the proportion was less than 10.0%.Electron microscopy showed the deposition of"hump"-like electron-dense deposits under the epithelium,and one case had more electron-dense deposits than the others.Immunofluorescence showed that only 9 cases(42.9%)had C3 deposition(≥++)but no IgG deposition,and only 2 cases had significant IgG deposition(≥++).The incidence of gross hematuria and acute kidney injur(y AKI)in the nephrotic proteinuria group was higher than that in the non-nephrotic proteinuria group,while the anti streptococcus hemolysin"O"test positive rate and albumin level were lower than those in the non-nephrotic proteinuria group(P<0.05).In addition to anti-infective and symptomatic treatment,6 patients in the nephrotic proteinuria group were also given glucocorticoid treatment,while no hormones were administered in the non-nephrotic proteinuria group.Time to disappearance of macroscopic hematuria,resolution of edema,conversion to negative urinary protein,and recovery of complement were longer in the nephrotic proteinuria group than in the non-nephrotic proteinuria group(P<0.05).Conclusions The incidence of AKI in children with acute streptococcal glomerulonephritis is high,but the prognosis is good.Only a few cases show hematuria following microscopy.