时间平均尿红细胞水平影响IgA肾病患者预后的临床研究

The Association of the Time-average Urinary Red Blood Cell and Kidney Disease Progression in IgA Nephropathy

目的:探讨不同尿红细胞水平与IgA肾病患者临床指标、病理、及预后的关系。方法:经肾活检确诊为原发性IgA肾病患者,根据时间平均尿红细胞(time average urinary red blood cell,TA-uRBC)检测结果的三分位数分为低、中、高三组,分析比较各组的临床病理及预后,主要结局事件定义为死亡,或到达肾脏结局[包含终末期肾衰竭(透析,移植),或肾小球滤过率下降大于40%]。结果:共纳入540例IgAN患者,尿红细胞水平与年龄(r=-0.142,P=0.001)、平均动脉压(r=-0.094,P=0.049)、与eGFR水平(r=0.091,P=0.04)正相关。尿红细胞水平与病理损伤中的新月体比例(r=0.196,P<0.0001)、系膜细胞增生程度(r=0.097,P=0.03)、毛细血管内细胞增生程度(r=0.093,P=0.04)呈正相关。与节段性硬化、小管萎缩/间质纤维化无相关性(P>0.05)。随访65(IQR 51.00~103.00)个月,随访期间共计40例患者(7.41%)到达终点事件,其中6例进入ESRD,34例GFR下降>40%。Kaplan-Meier生存分析结果表明低、中、高组的肾脏生存率依次降低(P=0.045);多因素COX回归提示TA-uRBC每升高10/HP,肾功能进展至结局的风险增加45.4%,(95%CI 1.185~1.785),P=0.0003。进一步进行亚组分析,对24 h尿蛋白定量>0.74 g(中位数)的患者,各组生存曲线差异有统计学意义(P=0.045),肾脏预后与TA-uRBC水平(r=1.063,P=0.0005)正相关;而24 h尿蛋白定量<0.74 g的患者各组间则差异无统计学意义。结论:IgA肾病血尿水平与新月体形成正相关。持续存在血尿且其平均水平与IgAN的预后相关。

Objective:This study aimed to evaluate the association of hematuria and progression of IgAN.Methods:A cohort of 540 patients with IgA nephropathy were followed for a Median of 65 months.The cohort group was subsequently divided into 3 groups(Low-uRBC,Medium-uRBC,and High-uRBC)according to the results of the time average urinary red blood cell(TA-uRBC).Renal survival and the relationships between clinical parameters and renal outcomes were assessed.Results:The TA-uRBC was negatively correlated with age and mean arterial pressure,and positively correlated with EGFR.TA-uRBC were positively correlated with crescent formation(r=0.196,P<0.0001),mesangial cell proliferation(r=0.097,P=0.03)and endocapillary hypercellularity(r=0.093,P=0.04).There was no correlation between urine red blood cells with segmental sclerosis,tubular atrophy/interstitial fibrosis(P>0.05).The analysis of the survival curve of each group showed that the renal survival rate in the high urinary erythrocyte group,the intermediate urinary erythrocyte group,and the low urinary erythrocyte group were decreased sequentially,with a statistically significant difference(P=0.045).Multivariate Cox model showed that for every 10/HP increase in microscopic hematuria,risk for the combine event increased 45.4%(95%CI 1.185~1.785).Further analysis found that in the patients with a 24-hour urinary protein quantification>0.75 g,the survival curves in the high urinary erythrocyte group,the intermediate urinary erythrocyte group,and the low urinary erythrocyte group decreased sequentially,with a statistically significant difference(P=0.045).However,there was no significant difference among groups with 24-hour urine protein<0.74 g.Conclusion:Persistent hematuria and the time-average level are associated with the prognosis of IgAN.