儿童紫癜性肾炎并高尿酸血症的临床及肾脏病理特征

Clinical manifestations and pathological characteristics of Henoch-Schonlein purpura nephritis combined with hyperuricemia in children

目的探讨儿童紫癜性肾炎并高尿酸血症的临床及肾脏病理特征。方法对2014年1月至2018年5月在首都儿科研究所附属儿童医院肾脏病房住院的50例紫癜性肾炎患儿的临床及病理资料进行回顾性分析,比较并高尿酸血症组(19例)与正常尿酸组(31例)患儿年龄、性别、血压、血清蛋白、24h尿蛋白定量、血肌酐、三酰甘油、胆固醇、高密度脂蛋白、低密度脂蛋白、血尿酸、估算肾小球滤过率、肾组织病理学结果的差异,并对近期预后进行分析。结果1.尿蛋白定量在高尿酸血症组为(91.67±90.37)mg/(kg·d),在正常尿酸组为(64.62±43.28)mg/(kg·d),二者比较差异有统计学意义(t=2.04,P=0.047),且伴有大量蛋白尿者在高尿酸血症组为18/19例(94.7%),在正常尿酸组中为17/31例(54.8%),二者比较差异有统计学意义(χ^2=8.930,P=0.003)。2.所有病例中,肾小球病理Ⅱ级4例,Ⅲ级43例,Ⅳ级3例,高尿酸血症组及正常尿酸组中病理分级均以Ⅲ级为主,其中高尿酸血症组16/19例(84.2%),正常尿酸组中27/31例(87.1%),而4例Ⅱ级者均为正常尿酸组,3例Ⅳ级者均为高尿酸血症组,高尿酸血症组病理分级相对偏重,差异有统计学意义(χ^2=7.358,P=0.025)。在高尿酸血症组和正常尿酸组中,球性硬化、系膜增生程度差异无统计学意义(χ^2=2.426,P=0.119,χ^2=0.043,P=0.836);足突严重病变者(即足突广泛融合、脱落)在高尿酸血症组中比例[7/19例(36.8%)]明显高于正常尿酸组[4/31例(12.9%)],差异有统计学意义(χ^2=3.934,P=0.047)。高尿酸血症组所有病例均出现不同程度肾小管间质改变,(+)级9/19例(47.4%),(++)级10/19(52.6%),而正常尿酸组中有12/31例(38.7%)患儿无肾小管间质改变,(+)级和(++)级改变亦低于高尿酸血症组(χ^2=10.694,P=0.005)。肾小管萎缩、间质纤维化在高尿酸血症组平均积分(1.00±0.00)明显高于正常尿酸组(0.61±0.50),差异有统计学意义(t=2.36,P=0.001)。3.自肾活检至末次复诊时间间隔在高尿酸血症组与正常尿酸组分别平均为10.0个月、10.5个月,2组比较差异无统计学意义(P=0.85);高尿酸血症组完全缓解5/19例(26.3%)、轻微异常10/19例(52.6%)、严重异常4/19例(21.1%),正常尿酸组完全缓解19/31例(61.3%)、轻微异常10/31例(32.3%)、严重异常2/31例(6.5%),高尿酸血症组中未缓解病例明显高于正常尿酸组,差异有统计学意义(χ^2=7.878,P=0.042)。结论并高尿酸血症的紫癜性肾炎患儿尿蛋白量更高,肾小管间质、肾小球病理分级及足突改变均较正常尿酸组患儿严重,可作为预后不良的影响因素。

Objective To analyze the relationship of clinical manifestations and pathological characteristics of Henoch-Sch?nlein purpura nephritis combined with hyperuricemia in children. Methods A retrospective study was conducted in 50 children with Henoch-Sch?nlein purpura nephritis who hospitalized at Department of Nephrology, Affiliated Children′s Hospital, Capital Institute of Pediatrics from January 2014 to May 2018.The differences between the hyperuricemia group(19 cases)and the normal uric acid group(31 cases), were compared in age, sex, blood pressure, serum albumin, 24-hour urinary protein, serum creatinine, triglyceride, cholesterol, high density lipoprotein, low density lipoprotein, serum uric acid, estimated glomerular filtration rate, and renal pathological characteristics, and the short-term prognosis was analyzed. Results (1)The average urinary protein in the hyperuricemia group and the normal uric acid group was (91.67±90.37) mg/(kg·d) and (64.62±43.28) mg/(kg·d), respectively and the difference was statistically significant between the both groups(t=2.04, P=0.047);and the morbidity with massive proteinuria in hyperuricemia group and normal uric acid group was 18/19 cases(94.7%)and 17/31 cases(54.8%), respectively and the difference was statistically significant between the both groups(χ^2=8.930, P=0.003).(2)In all cases, there were 4 cases of glomerular pathological grade Ⅱ, 43 cases of grade Ⅲ and 3 cases of grade Ⅳ.The pathological grading of hyperuricemia group and normal uric acid group was mainly grade Ⅲ, including 16/19 cases (84.2%) in hyperuricemia group and 27/31 cases (87.1%) in normal uric acid group, 4 cases of grade Ⅱ in normal uric acid group and 3 cases of grade Ⅳ in hyperuricemia group, the pathological grade of hyperuricemia group was relatively severe (χ^2=7.358, P=0.025). There was no significant difference about the degree of global sclerosis and mesangial proliferation between hyperuricemia group and normal uric acid group(χ^2=2.426, P=0.119,χ^2=0.043, P=0.836, respectively);7/19 cases (36.8%) had severe foot process lesions in hyperuricemia group, which was significantly higher than that in normal uric acid group [4/31 cases(12.9%)](χ^2=3.934, P=0.047). In hyperuricemia group, tubulointerstitial lesions were found in 9/19 cases (47.4%) of (+) grade and 10/19 cases (52.6%) of (++) grade, and 12/31 cases (38.7%) had normal tubulointerstitium in normal uric acid group,(+)and (++)grade lesions were also less than those in the hyperuricemia group(χ^2=10.694, P=0.005). The mean scores of tubular atrophy and interstitial fibrosis were significantly higher in hyperuricemia group than that in normal uric acid group(t=2.36, P=0.001).(3) The interval from renal biopsy to final visit was 10.0 months and 10.5 monthsin hyperuricemia group and normal uric acid group respectively (P=0.85). In hyperuricemia group, complete remission was found in 5/19 cases (26.3%), slight abnormality in 10/19 cases (52.6%), severe abnormality in 4/19 cases (21.1%). Howe-ver, in normal uric acid group, complete remission was found in 19/31 cases (61.3%), 10/31 cases (32.3%) of slight abnormalities and 2/31 cases (6.5%)of severe abnormalities.The non-remission cases in the hyperuricemia group were significantly higher than those in the normal uric acid group(χ^2=7.878, P=0.042). Conclusions Urinary protein was higher in children with Henoch-Sch?nlein purpura nephritis complicated with hyperuricemia, the pathological of renal tubulointerstitium and glomerulus and the foot process change are more serious than those of patients with normal uric acid.Therefore, hyperuricemia may be used as a risk factor for poor prognosis.