特发性膜性肾病的临床病理特征和诊治研究
发布时间：2018-09-01 14:09
【摘要】：【目的】本研究将分析特发性膜性肾病（IMN）的临床病理表现、诊断与治疗，以进一步提高本病的诊治水平。 【方法】1）收集2009.01-2013.10我科肾穿确诊IMN患者共475例，比较其各项指标并分析其临床与病理联系。2）对2010.03-2012.09经肾脏病理活检确诊的IMN患者212例和V型及V型合并其他类型狼疮性肾炎（MLN）患者28例的肾组织进行IgG亚型免疫荧光检测并进行比较。3）回顾性分析2008.04-2013.02我科68例采用不同治疗方法（激素联合CsA或CTX），并随访一年以上的IMN患者。分析、比较两组患者的治疗效果及不良事件。 【结果】1）5年间IMN发病率呈上升趋势。475例患者男女比例1.11:1，平均年龄53.0±14.9岁。不同年龄分组的IMN患者心血管危险因素随年龄升高趋于严重，表现为血红蛋白下降、空腹血糖上升、收缩压及舒张压的升高（P均0.01）。肾组织免疫荧光以IgG（97.2%）及C3（73.6%）沉积为主，病理分期则以I期（25.3%）及II期（58.3%）为主，III期（15.6%）及IV期（0.8%）相对较少。2）IMN不同病理分期IgG亚型分布的百分比无明显差异，均以IgG4沉积为主（I期100%、II期93.8%、III期85.7%）；非NS组的IgG3（P=0.013）及IgG4（P=0.02）亚型沉积荧光平均强度均高于NS组；MLN患者肾组织活检沉积以非IgG4沉积为主，其所有IgG亚型沉积荧光平均强度与IMN患者相比有显著差异性（P均0.001）。3）两种治疗方法均能有效降低IMN患者蛋白尿及升高血浆白蛋白，CsA组短期（3月）的缓解率高于CTX组，但随访1年的两组缓解率无明显差异（85.2%vs75.0%，P=0.212）。CsA组随访1年的eGFR较基线值显著降低（104.1±31.7vs82.9±26.8ml/min/1.73m2，P0.001）。CsA组患者有5例在治疗期间出现糖耐量受损/糖尿病；CTX组1例患者糖耐量受损，2例患者发生严重的肺部感染，其中1例合并急性肾盂肾炎。 【结论】IMN是一种常见的肾脏病，以中老年人多见，，男性多于女性。不同年龄段IMN患者有各自的临床特征；IMN肾组织以IgG4沉积为主，而MLN以非IgG4为主。肾组织IgG亚型检测有助于两者的鉴别；激素联合CsA或CTX均能有效缓解IMN患者病情。CsA可能会使肾功能减退，而CTX可能会诱发感染事件，这些副作用需要引起临床医生的注意。
[Abstract]:[objective] to analyze the clinicopathological features, diagnosis and treatment of idiopathic membranous nephropathy (IMN) in order to further improve the diagnosis and treatment of this disease. [methods] 1) 475 patients with IMN diagnosed by renal puncture in our department from January to March 2010 were collected. Comparing its indexes and analyzing its clinical and pathological relation .2) the renal tissues of 212 IMN patients diagnosed by renal pathological biopsy and 28 patients with (MLN) of V type and V type associated with other types of lupus nephritis were examined with IgG subtype immunofluorescence from 2010.03-2012.09. A retrospective analysis of 68 patients with IMN who were treated with different treatments (hormone combined with CsA or CTX),) from April to March, 2008.04-2013.The patients were followed up for more than one year. The therapeutic effect and adverse events of the two groups were compared. [results] 1) the incidence of IMN increased in 5 years. The ratio of male to female was 1.11: 1 with an average age of 53.0 卤14.9 years. The cardiovascular risk factors of IMN patients in different age groups tended to be serious with the increase of age, such as the decrease of hemoglobin, the increase of fasting blood glucose, and the increase of systolic and diastolic blood pressure (P0.01). IgG (97.2%) and C3 (73.6%) were mainly deposited in renal tissues, while the percentage of IgG subtypes in different stages of IMN was not significantly different among stages I (25.3%), II (58.3%), III (15.6%) and IV (0.8%). The average intensity of IgG4 deposition in IgG3 (P0. 013) and IgG4 (P0. 02) subtypes in non NS group was higher than that in NS group. The average fluorescence intensity of deposition of all IgG subtypes was significantly different from that of IMN patients (P all 0.001). Both of the two treatments could effectively reduce proteinuria and increase the remission rate of short term (3 months) in IMN patients with elevated plasma albumin CSA compared with those in CTX group. But there was no significant difference in remission rate between the two groups (85.2 vs 75.0 and P0.212). The eGFR of CSA group was significantly lower than the baseline value (104.1 卤26.8ml / min / 1.73m2P0.001). Five patients in CSA group had impaired glucose tolerance / diabetes during treatment. In CTX group, one patient with impaired glucose tolerance and two patients with severe pulmonary infection developed severe pulmonary infection. [conclusion] IMN is a common renal disease, most of which are middle and old people, male is more than female. Different age groups of IMN patients had their own clinical features: IgG4 deposition was the main renal tissue, and MLN was non-IgG4. The detection of IgG subtypes in renal tissue is helpful for the differentiation of the two, and hormone combined with CsA or CTX can effectively alleviate the renal dysfunction in patients with IMN, while CTX may induce infection events, these side effects need the attention of clinicians.
【学位授予单位】：上海交通大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R692
[Abstract]:[objective] to analyze the clinicopathological features, diagnosis and treatment of idiopathic membranous nephropathy (IMN) in order to further improve the diagnosis and treatment of this disease. [methods] 1) 475 patients with IMN diagnosed by renal puncture in our department from January to March 2010 were collected. Comparing its indexes and analyzing its clinical and pathological relation .2) the renal tissues of 212 IMN patients diagnosed by renal pathological biopsy and 28 patients with (MLN) of V type and V type associated with other types of lupus nephritis were examined with IgG subtype immunofluorescence from 2010.03-2012.09. A retrospective analysis of 68 patients with IMN who were treated with different treatments (hormone combined with CsA or CTX),) from April to March, 2008.04-2013.The patients were followed up for more than one year. The therapeutic effect and adverse events of the two groups were compared. [results] 1) the incidence of IMN increased in 5 years. The ratio of male to female was 1.11: 1 with an average age of 53.0 卤14.9 years. The cardiovascular risk factors of IMN patients in different age groups tended to be serious with the increase of age, such as the decrease of hemoglobin, the increase of fasting blood glucose, and the increase of systolic and diastolic blood pressure (P0.01). IgG (97.2%) and C3 (73.6%) were mainly deposited in renal tissues, while the percentage of IgG subtypes in different stages of IMN was not significantly different among stages I (25.3%), II (58.3%), III (15.6%) and IV (0.8%). The average intensity of IgG4 deposition in IgG3 (P0. 013) and IgG4 (P0. 02) subtypes in non NS group was higher than that in NS group. The average fluorescence intensity of deposition of all IgG subtypes was significantly different from that of IMN patients (P all 0.001). Both of the two treatments could effectively reduce proteinuria and increase the remission rate of short term (3 months) in IMN patients with elevated plasma albumin CSA compared with those in CTX group. But there was no significant difference in remission rate between the two groups (85.2 vs 75.0 and P0.212). The eGFR of CSA group was significantly lower than the baseline value (104.1 卤26.8ml / min / 1.73m2P0.001). Five patients in CSA group had impaired glucose tolerance / diabetes during treatment. In CTX group, one patient with impaired glucose tolerance and two patients with severe pulmonary infection developed severe pulmonary infection. [conclusion] IMN is a common renal disease, most of which are middle and old people, male is more than female. Different age groups of IMN patients had their own clinical features: IgG4 deposition was the main renal tissue, and MLN was non-IgG4. The detection of IgG subtypes in renal tissue is helpful for the differentiation of the two, and hormone combined with CsA or CTX can effectively alleviate the renal dysfunction in patients with IMN, while CTX may induce infection events, these side effects need the attention of clinicians.
【学位授予单位】：上海交通大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R692
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相关期刊论文 前10条
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3 李s
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