含汞化妆品相关肾病的临床病理特征及预后

Clinico-pathological characteristics and outcome of glomerulonephropathy in patients with mercury-including cosmetics

目的:探讨使用含汞化妆品后出现肾脏疾病的临床病理特征、治疗及预后。方法:回顾性分析2013年1月至2019年12月间结合病史、临床、肾活检和尿汞检测诊断为含汞化妆品相关肾病患者的临床表现、实验室指标、肾脏病理特点、治疗及预后。结果:共收集41例患者,均为女性,平均年龄39.4±6.6岁,使用含汞化妆品中位时间为6月,平均尿汞水平为66.80±38.55μg/(g·Cr),临床表现以蛋白尿为主,多数患者(32/41,78.05%)为肾病综合征。肾活检病理:膜性肾病(MN)22例(53.65%)、微小病变肾病(MCD)13例(31.71%)、IgA肾病(微小病变型)(IgAN-MCD)5例(12.20%)、局灶节段肾小球硬化(FSGS)1例(2.44%)。病理表现为MN的患者发病前含汞化妆品使用的中位时间更长、合并自身抗体阳性的(以ANA为主)比例(7/22)更高,且血抗磷脂酶A2受体抗体(PLA2R-Ab)及肾组织抗磷脂酶A2受体(PLA2R)均阴性。接受激素和(或)免疫抑制剂治疗36例、血管紧张素受体拮抗剂(ARB)治疗5例,其中9例同时接受驱汞治疗。中位随访时间9月,尿检达完全缓解32例(78.05%),8例(19.51%)部分缓解,1例(2.44%)未缓解,激素减量后复发1例,15例成功停用免疫抑制剂及保肾药物。结论:含汞化妆品相关肾病临床主要表现为肾病综合征,肾小球病变多样,以MN为主,其次为MCD,激素或免疫抑制剂治疗后缓解率高,预后佳。

Objective:To investigate the clinicopathological features,treatment and prognosis of glomerulonephropathy caused by mercury-including cosmetics.Methodology:A retrospective analysis of patients diagnosed as mercury-induced glomerulonephropathy by medical history,clinical,renal biopsy and urine mercury detection due to skin lighting cream from January 2013 to December 2019 in Jinling Hospital was performed.Clinical manifestations,laboratory test,renal pathological characteristics,treatment and prognosis were analyzed.Results:A total of 41 cases were collected.They were all females,with an average age of(39.4±6.6)years at diagnosis.The median time of exposure to skin lighting cream was 6 months,and the average urine mercury level was 66.80±38.55μg/(g·Cr).Most patients(32/41)were presented with nephrotic syndrome(NS).Renal histopathology showed membranous nephropathy(MN)in 22 patients(53.65%),minimal change disease(MCD)in 13 patients(31.71%),IgAN-MCD in 5 patients(12.20%)and focal segmental glomerulosclerosis(FSGS)in 1 patient(2.44%).Median time of exposure to mercury was longer and proportion of patients with autoantibodies(mainly ANA)was higher in patients with MN.Both of blood phospholipase A2 receptor(PLA2 R)-Ab and kidney tissue PLA2 R were negative.Thirty-six patients received glucocorticoid and/or immunosuppressant,5 patients were treated with angiotensin receptor blocker(ARB).Nine patients were combined with mercury detoxification.Thirty-two patients(78.05%)achieved complete remission(CR)in 1.0(range 0.5~11.0)months,8 patients(19.51%)achieved partial remission(PR).One patient relapsed during glucocorticoid withdraw,and 15 patients discontinued the drugs successfully.Conclusion:MN was the most common pathological type in mercury-induced glomerulonephropathy,followed by MCD and IgAN-MCD.Most patients could achieve remission after immunosuppressive therapy.