ANCA相关性小血管炎患者肺部影像改变的特点及对预后的影响

发布时间：2018-05-11 00:25

本文选题：肺部影像 + 抗中性粒细胞胞浆抗体　；参考：《浙江大学》2017年硕士论文

【摘要】：背景与目的:肺部影像改变在ANCA相关小血管炎(AAV)患者中常见,肺部纤维化(PF)等病变也越来越得到关注,目前国内有关AAV病人不同肺部影像表现的研究较少。本研究目的在于分析我们中心AAV患者的资料,得到AAV患者肺部影像改变的特点及对预后的影响结果。方法:本研究纳入2009年3月-2015年12月于浙江大学医学院附属第一医院诊断为AAV患者,共136例。初始的一般情况、血清学数据、影像学检查报告以及随访和终点数据。根据肺部影像是否阳性将纳入的对象分为两组进行比较,分析出有显著性差异的指标;再分别以终末期肾病和死亡事件为终点事件制作Kaplan-Meier生存曲线,以观察肺部影像改变对预后的影响情况;以肺部影像阳性的患者中肺部纹理的改变程度为依据进行分组,来比较肺部影像阳性的各亚组之间的差别;然后根据结局是否为终末期肾病以及是否存活各分为两组分别进行比较,得到影响患者终末期肾病和存活的指标,再建立COX回归模型后分别得到两者的独立危险因素。结果:1.根据患者肺部影像是否有改变将136例患者分为阴性组和阳性组,病例数分别为43例(31.6%)和93例(68.4%)。根据肺部影像阳性93例患者的影像学表现的程度不同,将其分为三个亚组,分别为仅肺纹理增多组、条索斑片毛玻璃组和网格蜂窝改变组,病例数分别为40例(43.0%)、35例(37.6%)和18例(19.4%)。根据结局是否为终末期肾病分为两大组,分别是非终末期肾病组83例(61.02%)和终末期肾病组53例(38.97%);根据结局是否死亡分为两大组,分别是存活组114例(83.82%)和死亡组22例(16.18%)。终末期肾病定义为患者持续血透或腹透时间至少6周且肾功能未能有所恢复。2.在肺部影像阳性组和阴性组初始资料的比较中,年龄有显著性差异,肺部影像阳性组年龄偏大(P = 0.021);血清肌酐水平、CRP有显著性差异,肺部影像阳性组的Cr(P = 0.019)、CRP(P = 0.022)均显著高于肺部影像阴性组;肾脏病理、治疗及预后均没有显著性差异。以终末期肾病为终点事件,制作Kaplan-Meier生存曲线比较阳性组和阴性组差异(LogRank=0.045);以死亡为终点事件,制作Kaplan-Meier生存曲线比较阳性组和阴性组差异(LogRank=0.774)。进一步将肺部影像阳性分为三个亚组,进行亚组之间比较,一般情况、检验结果、肾脏病理、治疗及预后均未发现明显差别。3.在结局非终末期肾病组与终末期肾病组的比较中,高血压、发热、肺部影像改变有显著性差异。其中,非终末期肾病组的高血压(P = 0.036)以及肺部影像阳性患者(P = 0.038)显著少于终末期肾病组;而发热患者是以前者居多(P=0.030);HB、PLT、GLO、Cr、eGFR、蛋白尿、PTH均有显著性差异,肾脏病理及治疗均没有显著性差异。建立COX回归模型发现终末期肾病的独立危险因素分别为蛋白尿(P = 0.012)、eGFR(P = 0.07)。在结局存活组与死亡组的比较中,存活组的随访时间较长(P = 0.000);eGFR有显著性差异(P = 0.001);终末期肾病发生率有显著性差异(P0.001)。建立COX回归模型发现终末期肾病是死亡的独立危险因素。结论:肺部影像阳性的ANCA相关小血管炎患者起病时肌酐更高,肾脏预后更差;但肺部影像阳性表现的严重程度对预后无显著性影响;肺部影像阳性并不是影响患者预后的独立危险因素,蛋白尿、eGFR是终末期肾病预后的独立危险因素。
[Abstract]:Background and purpose: pulmonary imaging changes are common in patients with ANCA associated vasculitis (AAV). Pulmonary fibrosis (PF) and other lesions are becoming more and more concerned. There are few studies on different pulmonary imaging manifestations of AAV patients at home. The purpose of this study is to analyze the data of the patients with AAV in our center, and to obtain the specific lung imaging changes of the AAV patients. Methods: This study included 136 cases of AAV in the first hospital affiliated to the Zhejiang University Medical College, Zhejiang University, March 2009. The initial general situation, serological data, imaging reports, and follow-up and end point data were divided into two groups according to whether the lung images were positive. The Kaplan-Meier survival curve was produced with end-stage renal disease and death events to observe the effect of pulmonary imaging changes on prognosis, and to compare the pulmonary texture changes in patients with positive lung images to compare the positive pulmonary images. The difference between the various subgroups; then according to the outcome of end-stage renal disease and whether the survival was divided into two groups, the index of end-stage renal disease and survival was obtained, and the independent risk factors were obtained after the COX regression model. Results: 1. according to whether the pulmonary images were changed in 136 cases, 136 patients were affected. The cases were divided into negative group and positive group, the number of cases were 43 cases (31.6%) and 93 cases (68.4%). According to the degree of imaging manifestation of 93 patients with positive lung imaging, they were divided into three subgroups, which were only lung texture group, streak patch wool glass group and grid bee nest change group, the number of cases was 40 cases (43%), 35 cases (37.6%) and 18. Cases (19.4%) were divided into two groups according to the outcome of end-stage renal disease, 83 cases (61.02%) and 53 cases of end-stage renal disease (38.97%) in non end-stage renal disease group; two groups were divided into two groups according to the outcome, 114 (83.82%) and 22 cases (16.18%) in the death group. End-stage renal disease was defined as the patient's continuous hemodialysis or peritoneal dialysis time. There was a significant difference in age between the lung imaging positive group and the negative group, and the age of the lung imaging positive group was significantly different (P = 0.021), and the serum creatinine level was significantly different between the.2. positive group and the negative group. The serum creatinine level, the Cr (P = 0.019) and CRP (P = 0.022) in the lung imaging positive group were significantly higher than those of the lung imaging negative. There was no significant difference in renal pathology, treatment and prognosis. End-stage renal disease was the end event, the Kaplan-Meier survival curve was compared positive group and negative group (LogRank=0.045); the Kaplan-Meier survival curve was compared between positive group and negative group (LogRank=0.774). The positive was divided into three subgroups, and compared with the subgroups, the general situation, the test results, the renal pathology, the treatment and the prognosis were not significantly different.3. in the outcome of the non end-stage renal disease group and the end stage renal disease group, hypertension, fever, lung imaging changes have significant differences. Among them, non end-stage renal disease hypertension (P = 0.036) And the lung imaging positive patients (P = 0.038) were significantly less than the end stage renal disease group (P=0.030), while the fever patients were most former (P=0.030); HB, PLT, GLO, Cr, eGFR, proteinuria, PTH had significant differences, and there was no significant difference in renal pathology and treatment. The independent risk factors for the establishment of the COX regression model were proteinuria (P). = 0.012), eGFR (P = 0.07). In the survival group compared with the death group, the follow-up time of the survival group was longer (P = 0); there was a significant difference in eGFR (P = 0.001); the incidence of end-stage renal disease was significantly different (P0.001). The establishment of COX regression model found that terminal nephropathy was an independent risk factor for death. Conclusion: ANC with positive lung imaging. The patients with A related small vasculitis have higher creatinine and worse renal prognosis, but the severity of lung imaging positive expression has no significant effect on prognosis; pulmonary imaging positive is not an independent risk factor affecting the prognosis of the patients. Proteinuria and eGFR are independent risk factors for the prognosis of end-stage renal disease.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R593.2

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