HIV感染合并慢性肾脏病患者的临床和肾脏病理特征

Clinical and renal pathologic characteristics of HIV infection patients combined with chronic kidney disease

目的:探讨人类免疫缺陷病毒(HIV)感染合并慢性肾脏病患者的临床、肾脏病理特征及临床转归。方法:收集2018年7月至2022年12月南京市公共卫生医疗中心电子病历系统中确诊的HIV感染合并慢性肾脏病(CKD)患者,将2年内估测肾小球滤过率(eGFR)下降>30%、血液透析、腹膜透析、接受肾移植或死亡的患者纳入CKD进展组,其余患者纳入CKD稳定组,比较两组患者的临床及肾脏病理特征。结果:本研究纳入HIV感染合并CKD患者37例,其中男性34例(91.89%)。IgA肾病(IgAN)、系膜增生性肾小球肾炎(MsPGN)、膜性肾病(MN)是HIV感染合并CKD中常见三大病理类型,分别占比33.3%,18.2%,13.51%。局灶节段性肾小球硬化(FSGS)病理表现并非典型HIV相关性肾病(HIVAN)。26例患者(70.27%)有肾间质纤维化,32例患者(86.49%)有急性肾小管损伤。与CKD稳定组比较,CKD进展组24 h尿蛋白定量更高、血白蛋白及血红蛋白更低、CKD起病时尿潜血阳性发生比例更高,差异有统计学意义(P<0.05)。肾穿刺前13例用拉米夫定(STC)+替诺福韦(TDF)+依非韦伦(EFV)抗病毒治疗,肾穿刺后TDF从治疗方案中剔除。明确病因后予激素、免疫抑制剂治疗22例,血管紧张素受体拮抗剂(ARB)治疗23例,降尿酸治疗12例。最终死亡3例,透析4例,肾功能进展3例。结论:HIV感染合并CKD患者以男性为主;IgAN、MsPGN、MN是HIV感染合并CKD患者在本研究样本中的常见三大病理类型,肾间质纤维化及急性肾小管损伤发生率较高;抗病毒药物替诺福韦、肾毒性药物的使用及机会感染可能是肾间质病变的主要致病因素。

Objective:To investigate the clinical and nephropathologic characteristics and clinical regression of patients with human immunodeficiency virus(HIV)infection combined with chronic kidney disease(CKD).Methods:Patients with HIV infection combined with CKD diagnosed in the electronic medical record system of Nanjing Public Health Medical Center from July 2018 to December 2022 were collected,and patients with>30%decrease in estimated glomerular filtration rate(eGFR)within 2 years,hemodialysis,peritoneal dialysis,receiving renal transplantation,or death were included in the CKD progression group,while the rest of the patients were included in the CKD stabilization group.The clinical and renal pathologic characteristics of patients in the two groups were compared.Results:Thirty-seven patients with HIV infection combined with CKD were included in this study,of whom 34(91.89%)were male.IgAN,proliferative glomerulonephritis of the thylakoid membrane(MsPGN),and membranous nephropathy(MN)were the 3 most common types of pathology in HIV infection combined with CKD,which accounted for 33.3%,18.2%,and 13.51%of the cases,respectively.Focal segmental glomerulosclerosis(FSGS)was not typical of HIV associated nephropathy(HIVAN).26 patients(70.27%)had renal interstitial fibrosis and 32 patients(86.49%)had acute renal tubular injury.Compared with the CKD stable group,the patient in the CKD progression group had higher 24 h urine protein quantification,lower serum albumin and hemoglobin,higher proportion of positive urine occult blood at CKD onset,which were statistically significant(P<0.05).Thirteen cases were treated with antiviral therapy with lamivudine+tenofovir+efavirenz(3TC+TDF+EFV)before renal puncture,and tenofovir was removed from the treatment regimen after renal puncture.After the etiology was clarified,22 cases were treated with hormones and immunosuppressants,23 cases were treated with angiotensin receptor antagonists(ARB),and 12 cases were treated with uric acid-lowering therapy,and finally 3 cases died,4 cases were dialyzed,and 3 cases had progression of renal function.Conclusion:The majority of HIV infection patients with CKD were male.IgAN,MsPGN,and MN were the three most common pathologic types of HIV-infected patients with CKD in this study sample,and the incidence of interstitial fibrosis and acute tubular injury was high.The antiviral drug tenofovir,the use of nephrotoxic drugs,and opportunistic infections may be the main causative factors for interstitial renal lesions.