不同免疫抑制方案治疗成人特发性膜性肾病有效性及安全性的网状Meta分析

Effectiveness and safety of immunosuppressive regimens for adult idiopathic membranous nephropathy:network Meta-analysis

目的应用网状Meta分析方法评价不同免疫抑制方案治疗成人特发性膜性肾病(idiopathic membranous nephropathy,IMN)的有效性及安全性。方法系统检索Cochrane library、PubMed、Medline和Clinical Trial及中国知网、万方和维普期刊数据库建立至2020年5月30日公开发表的成人IMN免疫抑制治疗的临床随机对照试验(randomized controlled trial,RCT)进行网状Meta分析,以直接和间接比较方式评估最优治疗方案。结果共纳入51项随机对照研究,共计2955例,17种免疫抑制方案根据概率累积排序面积图排序,总缓解率方面,在糖皮质激素基础上,雷公藤多苷联合吗替麦考酚酯方案>雷公藤多苷方案>咪唑立宾方案>雷公藤多苷联合他克莫司方案>利妥昔单抗方案;在降低24 h尿蛋白定量方面,雷公藤多苷联合吗替麦考酚酯方案最优,其次为雷公藤多苷联合他克莫司、促肾上腺皮质激素、环孢素A联合来氟米特、雷公藤多苷;在保持血肌酐方面,雷公藤多苷联合吗替麦考酚酯最优,其次为雷公藤多苷联合来氟米特、苯丁酸氮芥、吗替麦考酚酯、来氟米特;在耐受性方面,雷公藤多苷最优,其次是他克莫司、雷公藤多苷联合来氟米特、来氟米特、雷公藤多苷联合他克莫司。结论雷公藤多苷联合吗替麦考酚酯方案无论是总缓解率还是降低尿蛋白、保持血清肌酐均为疗效最佳方案,安全性方面雷公藤多苷最佳,目前仍需更多高质量随机试验证据进行验证。

Objective To employ the method of network Meta-analysis for evaluating the effectiveness and safety of immunosuppressive regimens for adult idiopathic membranous nephropathy.Methods The relevant literatures were retrieved from the English databases of Cochrane Library,PubMed,MedLine and Clinical Trial and the Chinese databases of CNKI,Wanfang and VIP Journal from inception until May 30,2020 according to the inclusion and exclusion criteria.Randomized controlled trials(RCTs)of immunosuppressants for adult idiopathic membranous nephropathy were included.Network Meta-analysis was utilized for comparing the advantages of each treatment plan.Results Fifty-one RCTs involving 2955 patients were analyzed.The SUCRA showed that combined regimen of Tripterygium wilfordii&mycophenolate mofetil(MM)fared the best in total remission rate,followed by T.wilfordii,mizoribine,T.wilfordii plus tacrolimus and rituximab regimens.In terms of lowering 24-hour urinary protein,combined regimen of T.wilfordii&MM was optimal,followed T.wilfordii plus tacrolimus,adrenocorticotropic hormone,cyclosporine A plus leflunomide and T.wilfordii.In terms of serum creatinine,T.wilfordii plus MM regimen was ideal,followed by T.wilfordii plus leflunomide,chlorambucil,MM and leflunomide regimens.T.wilfordii regimen was the best in tolerability,followed by tacrolimus,T.wilfordii plus leflunomide,leflunomide and T.wilfordii plus tacrolimus regimens.Conclusion A combination of T.wilfordii polyglycosides and MM is the best solution and more high-quality randomized trials are required for verification.