缺血性肾损伤患者临床及病理特点分析

Analysis of clinical and pathological features in biopsy-proven ischemic renal injury patients

目的探讨缺血性肾损伤患者的临床和病理特点。方法回顾性收集2010—2018年于北京大学第一医院肾脏内科经肾穿刺病理诊断的缺血性肾损伤患者的临床资料,对肾脏小动脉、肾小球及肾小管间质病变(IFTA)的病理改变进行半定量分析,并分析临床和病理指标的相关性。结果共52例患者被纳入本研究,年龄为(45.0±12.7)岁,其中男性39例(75.0%)。50例(96.2%)患者有高血压病史,病程中位数为66(24,138)个月;41例(78.9%)患者有超重/肥胖。24 h尿蛋白量中位数为0.75(0.27,1.32)g,仅3例(5.8%)患者24 h尿蛋白量>3.0 g。15例(28.8%)患者有镜下血尿。27例(51.9%)患者估算的肾小球滤过率(eGFR)<60 ml·min-1·(1.73 m2)-1。小动脉血管内/外径比值为0.43±0.05,正常血管比例为29.0%±17.0%。21例(40.4%)患者有小动脉玻璃样变。小动脉血管内/外径比值与肾小球病变比例(rs=-0.312,P=0.024)及IFTA半定量评分(rs=-0.291,P=0.037)呈负相关,与eGFR呈正相关(r=0.339,P=0.014)。高血压病程及体重指数分别与小动脉血管内/外径比值呈负相关(rs=-0.303,P=0.029及rs=-0.274,P=0.050),与补体C3水平呈正相关(rs=0.358,P=0.020及rs=0.432,P=0.004)。结论缺血性肾损伤可见于中青年患者,以小-中等量蛋白尿伴不同程度eGFR下降为主要表现,少数患者可出现镜下血尿和大量蛋白尿。小动脉内/外径比值与肾小球病变比例及IFTA半定量评分呈负相关,与eGFR呈正相关。高血压及超重/肥胖与缺血性肾损伤血管病变密切相关。

Objective To investigate the clinical and pathological features of ischemia renal injury.Methods Patients with biopsy-proven ischemia renal injury in the Department of Nephrology,Peking University First Hospital from 2010 to 2018 were retrospectively enrolled in the present study.The demographic information and laboratory data were collected.And the severity of pathologic changes including glomeruli,arteriole and tubulo-interstitial fibrosis(IFTA)were semi-quantitatively scored.Arterioles with a ratio of inner/outer luminal diameter greater than 0.5 without hyalinosis were diagnosed as normal ones.The relationships between estimated glomerular filtration rate(eGFR),urine protein excretion and pathological changes were analyzed.Results A total of 52 patients were enrolled in the study,including 39 males(75.0%).The age of the patients was(45.0±12.7)years at biopsy.Among them,50 patients(96.2%)had a history of hypertension with a median duration of 66(24,138)months.Forty-one patients(78.9%)were overweight or obese.The median urinary protein excretion was 0.75(0.27,1.32)g/d with 3 cases over 3 g/d.Fifteen patients(28.8%)presented with microhematuria and twenty-seven patients(51.9%)with eGFR lower than 60 ml·min-1·(1.73 m2)-1,respectively.The ratio of arteriolar inner/outer luminal diameter was 0.43±0.05 and the percentage of normal arterioles was 29.0%±17.0%.There were 21 patients(40.4%)found with arteriole hyalinosis.The ratio of arteriolar inner/outer luminal diameter correlated with the percentage of glomerular lesions(rs=-0.312,P=0.024),the semiquantitative scale of IFTA(rs=-0.291,P=0.037)and eGFR(r=0.339,P=0.014),respectively.Hypertension duration and body mass index(BMI)showed a negative correlation with the ratio of arteriolar inner/outer luminal diameter(rs=-0.303,P=0.029 and rs=-0.274,P=0.050,respectively)and a positive correlation with serum complement 3 level(rs=0.358,P=0.020 and rs=0.432,P=0.004,respectively).Conclusions Renal ischemia injury may be found in young and middle-aged patients.The characteristic of clinical features is mild to moderate proteinuria accompanied with a certain degree of eGFR decline,while a small number of patients may have microhematuria and marked proteinuria.The ratio of arteriolar inner/outer luminal diameter has a negative correlation with the percentage of glomerular lesions and the semiquantitative scale of IFTA and a positive correlation with eGFR,respectively.Hypertension and obesity are closely related to vascular lesions.