糖皮质激素及环磷酰胺对IgA肾病疗效的比较

发布时间：2018-12-14 18:10

【摘要】：目的:IgA肾病(Immungloblulin A nepropathy,IgAN)是我国最常见的原发性肾小球疾病,尽管经过积极治疗,仍然有20-40%的患者会进展到终末期肾病。糖皮质激素(P)与环磷酰胺(CTX)对IgAN的治疗效果还存在争议。本研究选择我中心(四川省人民医院肾脏内科)IgAN患者,采用回顾性分析,探讨糖皮质激素、糖皮质激素联合环磷酰胺对IgAN疗效及安全性的影响。对象及方法:选取2006年1月1日至2016年6月30日于我院经肾活检确诊的原发IgAN,且随访时间≥6个月236例患者,收集其临床资料,实验室检查结果,肾脏病理资料,治疗方案,随访期间肾功能、蛋白尿变化情况和不良事件。将所有患者根据治疗方案分为三组,单用ARB/ACEI治疗组(RASI组),ARB/ACEI联合糖皮质激素治疗组(RASI+P组),ARB/ACEI联合糖皮质激素及环磷酰胺治疗组(P+CTX组),比较三组患者的预后和不良事件。结果:RASI组,RASI+P组,以及P+CTX组三组患者分别有71例、80例和85例,基线年龄、血压和病程无明显差异。其中,P+CTX组24小时尿蛋白比其余两组更高(1.5(0.9-2.5)vs.1.06(0.05-2.3)vs.1.2(0.9-2.6)g/d,P=0.001),P+CTX组e GFR比其余两组更低(64.7±35.3vs.91.2±33.4vs.89.3±30.5ml/min/1.73m2,P=1.70×10-8);肾病理活检结果提示P+CTX组肾损伤较严重(系膜细胞增生、袢坏死、节段性硬化、球性硬化、肾小管萎缩/间质纤维化、炎细胞浸润和血管病变发生比例均较前两组高),差异具有统计学意义(P0.05)。三组患者随访结果显示,经治疗后尿蛋白均有明显下降,P+CTX组更低(P0.05);e GFR均得到了提高,P+CTX组上升最显著;用Kaplan-Meier生存曲线分析三组肾存活率发现,单用RASI组及RASI+P组的肾脏预后优于P+CTX组,差异具有统计学意义(P0.05);以e GFR基线下降30%定义为终点事件时,发现RASI+P或RASI组肾存活率明显下降,P+CTX组较RASI组高,差异无统计学意义(P0.05)。RASI+P与P+CTX组不良反应类似(P0.05)。结论:RASI,RASI+P,以及P+CTX治疗均可明显降低IgA肾病患者的蛋白尿及延缓肾功能进展;糖皮质激素对于IgAN患者有良好的疗效和安全性;糖皮质激素联合环磷酰胺治疗对于肾脏病变较重的IgAN患者表现出良好的效果及安全性。
[Abstract]:Objective: IgA nephropathy (Immungloblulin A nepropathy,IgAN) is the most common primary glomerular disease in China. The therapeutic effect of glucocorticoid (P) and cyclophosphamide (CTX) on IgAN remains controversial. In this study, we studied the effects of glucocorticoid, glucocorticoid combined with cyclophosphamide on the efficacy and safety of IgAN patients in our center (Department of Renal Medicine, Sichuan Provincial people's Hospital). Participants and methods: 236 patients with primary IgAN, diagnosed by renal biopsy in our hospital from January 1, 2006 to June 30, 2016 were selected and followed up for more than 6 months. The clinical data, laboratory results, renal pathological data and treatment plan were collected. Renal function, proteinuria and adverse events during follow-up. All the patients were divided into three groups according to the treatment plan: ARB/ACEI group (RASI group), ARB/ACEI combined with glucocorticoid treatment group (RASI P group), ARB/ACEI combined with glucocorticoid and cyclophosphamide treatment group (P CTX group). The prognosis and adverse events of the three groups were compared. Results: there were 71 cases in, RASI P group in RASI group, 80 cases in, RASI P group and 85 cases in P CTX group. There was no significant difference in baseline age, blood pressure and course of disease. The 24-hour urinary protein in the, P CTX group was higher than that in the other two groups (1.5 (0.9-2.5) vs.1.06 (0.05-2.3) vs.1.2 (0.9-2.6) g / dnP ~ (0.001). E GFR in P CTX group was lower than that in the other two groups (64.7 卤35.3vs.91.2 卤33.4vs.89.3 卤30.5 ml / min / 1.73 m ~ (-2) P = 1.70 脳 10 ~ (-8). The renal injury was more serious in P CTX group (Mesangial cell proliferation, loop necrosis, segmental sclerosis, bulbar sclerosis, tubular atrophy / interstitial fibrosis, inflammatory cell infiltration and angiopathy were higher in P CTX group than in the former two groups). The difference was statistically significant (P0.05). The follow-up results of the three groups showed that the urine protein decreased significantly in the, P CTX group after treatment (P0.05); e GFR) and the increase in the, P CTX group was the most significant. The renal survival rate of the three groups was analyzed by Kaplan-Meier survival curve. The renal prognosis of RASI group and RASI P group was better than that of P CTX group (P0.05). When defined by 30% reduction of e GFR baseline, the renal survival rate in RASI P or RASI group was significantly lower than that in RASI group. There was no significant difference between, P CTX group and P CTX group (P0.05). Conclusion: RASI,RASI P and P CTX can significantly reduce proteinuria and delay the progression of renal function in patients with IgA nephropathy, glucocorticoid has good efficacy and safety in IgAN patients. Glucocorticoid combined with cyclophosphamide is effective and safe in patients with IgAN with severe renal lesions.
【学位授予单位】：遵义医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692.31

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