重复肾活检IgA肾病患者临床病理及预后分析

Clinicopathologic and Prognostic Analysis of IgA Nephropathy Patients Who Recepted Repeated Renal Biopsy

目的探讨接受重复肾活检的IgA肾病(IgAN)患者临床、病理特点及预后。方法收集2004年9月至2019年9月在郑州大学第一附属医院接受重复肾活检的IgAN患者共40例,比较两次肾活检时的临床及病理指标。3例患者失访,剩余37例患者采用1∶1配对,筛选出同时段、年龄、性别、基线肾小球滤过率、病理表现一致的37例未接受重复肾活检IgAN患者作为对照组比较预后。结果(1)一般资料及临床指标:重复肾活检患者男17例,女23例,两次肾活检中位间隔时间为59.50个月,重复肾活检时血肌酐(Scr)较第1次肾活检升高(P<0.001),肾小球滤过率(GFR)(P<0.001)及血红蛋白(P=0.04)较第1次肾活检下降,结合病史患者多存在24小时尿蛋白定量(24 h TP)持续未转阴、短期3个月内24 h TP或Scr升高。(2)病理指标:肾小球节段硬化及粘连(S)、肾小管萎缩/间质纤维化(T)、间质炎细胞浸润、嗜复红蛋白沉积、刷状缘脱落、蛋白管型及肾小动脉透明样变性病变患者比例重复肾活检时明显增高(P<0.05);S、T、间质炎细胞浸润、嗜复红蛋白沉积、刷状缘脱落、蛋白管型、肾小动脉透明样变性加重的患者重复肾活检时均较第1次肾活检时Scr增加,GFR下降。(3)第2次肾活检后用药方案与第1次肾活检相比19例患者免疫抑制治疗加强,11例患者免疫抑制治疗减弱,10例无明显变化。(4)经Kaplan-Meier法分析,两组IgAN患者的预后无差异。结论虽然肾活检为有创性操作,但当存在短期内24 h TP及Scr升高或24 h TP持续未缓解时,可考虑接受重复肾活检。临床指标对于病理指标改变无特异性提示作用,更加突出重复肾活检的重要性。本研究暂未能说明接受重复肾活检IgAN患者的预后更佳,但通过重复肾活检,可发现新发的活动性病理改变或原有病变的加重,对于指导治疗有积极作用。

Objective To investigate the clinical and pathological features and prognosis of IgA nephropathy(IgAN)patients undergoing repeated renal biopsy.Methods A total of 40 IgAN patients who underwent repeated renal biopsy in the First Affiliated Hospital of Zhengzhou University from September 2004 to September 2019 were collected,and the clinical and pathological indexes of the two renal biopsies were compared.Three patients were lost to follow-up,1∶1 matching was used to select 37 IgAN patients without repeated renal biopsy who had the same age,sex,baseline glomerular filtration rate and pathological manifestations as the control group to compare the prognosis.Results(1)General information and clinical indicators:repeat renal biopsy was performed in 17 males and 23 females,and the median interval between the two renal biopsies was 59.50 months.The serum creatinine(Scr)was higher than that of the first renal biopsy(P<0.001),and the glomerular filtration rate(GFR)(P<0.001)and hemoglobin(P=0.04)were lower than those of the first renal biopsy.Combined with the medical history,the patients mostly had 24-hour quantitative urine protein(24 h TP)positive continuously,increased 24 h TP or serum creatinine within 3 months.(2)Pathological indexes:the proportion of patients with glomerular segmental sclerosis and adhesion(S),renal tubular atrophy/interstitial fibrosis(T),interstitial inflammatory cell infiltration,fuchsinophilic protein deposition,brush border shedding,protein tubules and renal arteriolar hyaline degeneration were significantly increased during repeated renal biopsy(P<0.05).Patients with S,T,interstitial inflammatory cell infiltration,polytropic protein deposition,brush edge shedding,protein tubules,and aggravating hyaloid degeneration of renal arteriolae were all more Scr and eGFR decreased at repeated renal biopsy than at the first renal biopsy.(3)After repeated renal biopsy,immunosuppressive therapy was strengthened in 19 patients,immunosuppressive therapy was weakened in 11 patients,and no significant change was observed in 10 patients.(4)By Kaplan-Meier analysis,the prognosis of IgAN patients in the two groups showed no difference.Conclusion Although renal biopsy is an invasive procedure,repeated renal biopsy can be considered if 24 h TP and serum creatinine are increased in a short period or 24 h TP is not in remission continuously.Clinical indicators have no specific indication for pathological changes,which highlights the importance of repeated renal biopsy.In this study,it has not been shown that patients undergoing repeated renal biopsy for IgAN have a better prognosis.However,through repeated renal biopsy,new active pathological changes or aggravation of existing lesions can be found,which has a positive role in guiding treatment.