人类免疫缺陷病毒感染伴肾病患者的临床病理分析

Clinicopathological analysis of patients with human immunodeficiency virus infection and nephropathy

目的对行肾组织活检的人类免疫缺陷病毒(HIV)感染合并肾病患者进行病理分析。方法纳入2011年1月至2018年12月四川大学华西医院肾内科接受肾组织活检的HIV合并肾病患者,分析其病理特征、干预措施和预后等。结果共纳入9例患者,其中肾病综合征患者6例,急性肾功能损伤患者1例,慢性肾炎综合征患者2例。组织学诊断:肾小球微小病变患者3例,膜性肾病患者1例,塌陷型局灶节段性肾小球肾炎(FSGS)伴膜性肾病患者1例,FSGS非特异型(NOS)患者1例,急性间质性肾炎患者1例,Ig A肾病患者1例,糖尿病肾病患者1例。5例患者在肾组织活检时首诊HIV感染(其中塌陷型FSGS伴膜性肾病、糖尿病肾病、急性间质性肾炎各1例,2例为肾小球微小病变),其余4例在HIV感染确诊后的不同时期(均行抗逆转录病毒治疗)发病。并发症:糖尿病1例,梅毒感染1例,甲状腺功能减退2例,乙型肝炎病毒感染3例。随访情况:3例患者失访,6例患者随访期间未发生严重感染,其中2例仍有大量蛋白尿,其余4例患者血尿消失,肾功能恢复正常水平,复查尿蛋白定量显著减少至可疑阳性或24 h定量<300 mg/d。结论HIV感染者出现肾脏损伤的临床表现多样,可出现不同程度蛋白尿和(或)血尿,伴或不伴肾功能不全,病理类型不仅限于人类免疫缺陷病毒相关性肾病(HIVAN),可出现糖尿病肾病、肾小球轻微病变、膜性肾病、非塌陷型FSGS、急性间质性肾炎、Ig A肾病。肾组织活检有助于明确诊断。抗逆转录病毒治疗有效情况下,依据患者的病理诊断,有针对性地给予糖皮质激素及细胞毒药物,并加强随访,有助于改善患者预后。肾病患者应加强HIV筛查。

Objective To investigate the pathological characteristic of patients with human immunodeficiency virus(HIV)infection complicated with nephropathy and renal tissue biopsy.Methods Patients with HIV-associated nephropathy confirmed by renal biopsy in Department of Nephrology,West China Hospital of Sichuan University from January 2011 to December 2018 were collected.The pathological features,intervention and prognosis were analyzed,retrospectively.Results Nine patients were enrolled,including 6 cases with nephrotic syndrome,1 case with acute kidney injury and 2 cases with chronic nephritis syndrome.Histological diagnosis results showed that 3 cases were with minor change,1 case with membranous nephropathy,1 case with collapsed focal segmental glomerular sclerosis(FSGS)and membranous nephropathy,1 case with FSGS-not otherwise specified(NOS),1 case with acute interstitial nephritis,1 case with IgA nephropathy,1 case with diabetic nephropathy.HIV infection was first diagnosed in 5 cases at the time of renal biopsy(including 1 case with collapsed FSGS complicated with membranous nephropathy,1 case with diabetic nephropathy,1 case with acute interstitial nephritis,and 2 cases with minor change disease).The other 4 cases developed renal disease at different stages(all receiving antiretroviral therapy)after the diagnosis of HIV infection.Among them,1 case accompanied with diabetes,1 case with syphilis infection,2 cases with hypothyroidism and 3 cases with hepatitis B virus infection.During the following up,no severe infection case was observed.After treatment,2 cases remained heavy proteinuria,4 cases reached complete remission.Conclusions Besides HIV associated nephropathy(HIVAN),renal diseases with the HIV infection background include diabetic nephropathy,minor change disease,membranous nephropathy,FSGS,acute interstitial nephritis,IgA nephropathy and so on.They may manifest different clinical syndrome such as acute kidney injury,nephrotic syndrome,chronic nephritis.Renal biopsy is crucial to diagnose and treat the diseases.HIV screening in patients with kidney disease is important.In the case of effective antiretroviral therapy,targeted administration of glucocorticoids and cytotoxic drugs is safe.Multidisciplinary cooperation including doctors from department of nephrology,infectious disease,pathology and clinical pharmacy may improve the prognosis of HIV infected patients with renal diseases.