论文部分内容阅读
目的:观察IgA肾病(IgAN)患者重复肾活检与首次肾活检肾组织病变的动态变化,分析其与治疗及疾病预后的关系。方法:观察91例接受重复肾活检的IgAN患者两次肾活检肾组织病变变化,并结合临床和治疗反应进行分析。病理评分采用IgAN牛津分类标准,包括肾小球系膜细胞增生性病变(M)、毛细血管内增生性病变(E)、节段硬化或黏连性病变(S)、肾小管间质病变(T)、肾小球新月体形成(C)、毛细血管袢坏死性病变(N)。根据患者肾组织病理的病变特点分为增生性病变组(伴E、C、N病变)和非增生性病变组;根据两次肾活检临床指标变化分为:病情好转组、病情平稳组和病情进展组。分别从病理和临床两个层面动态地对首次肾活检和重复肾活检肾组织病理变化特点进行分析。结果:(1)增生性病变组患者免疫抑制剂使用率明显高于非增生性病变组(77%vs 23.3%,P<0.01)。经免疫抑制治疗,重复肾活检时患者增生性病变明显改善,肾小球N、E和C病变逆转比例分别达100%、85%和75.6%。但T病变持续进展,肾小球M、S病变无明显变化。(2)病情好转组患者的免疫抑制剂使用率明显高于病情进展组(72.2%vs 39.3%,P<0.01)。重复肾活检时,病情好转组的患者E、N病变消失,C病变明显改善(72.2%vs 16.7%,P<0.01);病情进展组的患者C、N病变无明显变化,但其比例明显高于病情好转组(C:57.1%vs 16.7%,P<0.01;N:25%vs 0,P<0.01)。肾小球M病变比例随临床病情好转而下降,随病情进展呈增加趋势,重复肾活检时病情进展组M病变比例显著高于病情好转者组(46.4%vs 13.9%,P<0.01)。无论患者临床病情好转还是进展,T病变均有加重而S病变则无变化。结论:IgAN患者肾小球增生性病变(E、C、N)经免疫抑制治疗后大多数可逆转或改善,同时伴随临床病情好转。IgAN患者肾组织M和T病变与预后关系密切,S病变与预后无关。上述结果为指导IgAN患者基于肾脏病变特点选择治疗方案提供了有力依据。
OBJECTIVE: To observe the dynamic changes of renal biopsy and primary renal biopsy in patients with IgA nephropathy (IgAN) and analyze its relationship with treatment and disease prognosis. Methods: The changes of renal biopsy in 91 cases of IgAN patients who underwent repeated renal biopsy were observed, and the clinical and therapeutic responses were analyzed. The pathological score was based on the IgAN Oxford classification criteria, including mesangial cell proliferative lesions (M), capillary proliferative lesions (E), segmental sclerosis or adhesions (S), tubulointerstitial lesions T), glomerular crescent formation (C), capillary loop necrosis (N). According to the characteristics of pathological lesions in patients with renal disease is divided into proliferative lesions group (with E, C, N lesions) and non-proliferative lesions group; according to two changes in renal biopsy clinical indicators are divided into: improved condition, stable condition and disease Progress group. The histopathological changes of renal tissue from the first renal biopsy and repeated renal biopsy were analyzed dynamically from the pathological and clinical aspects respectively. Results: (1) The immunosuppressive agents in patients with proliferative lesions were significantly higher than those in non-proliferative lesions (77% vs 23.3%, P <0.01). Immunosuppressive therapy, patients with repeated renal biopsy proliferative lesions was significantly improved, glomerular N, E and C lesions were 100%, 85% and 75.6%, respectively. However, T lesions continued to progress, glomerular M, S lesions no significant change. (2) The usage of immunosuppressive agents in patients with remission was significantly higher than that in patients with progression (72.2% vs 39.3%, P <0.01). Repeated renal biopsy, patients with improved disease group E, N lesions disappeared, C lesions improved significantly (72.2% vs 16.7%, P <0.01); disease progression group of patients with C, N lesions no significant change, but the proportion was significantly higher In the condition improvement group (C: 57.1% vs 16.7%, P <0.01; N: 25% vs 0, P <0.01). The proportion of M lesions in glomeruli decreased with the improvement of clinical condition, with the progression of the disease showed an increasing trend. The proportion of M lesions in the progress of the repeat renal biopsy was significantly higher than that in the improved condition (46.4% vs 13.9%, P <0.01). Regardless of the patient’s clinical condition improved or progress, T lesions have increased and S lesions were unchanged. CONCLUSIONS: Most glomerular proliferative lesions (E, C, N) in IgAN patients can be reversed or improved after immunosuppressive therapy, accompanied by clinical improvement. IgAN patients with renal tissue M and T lesions and prognosis are closely related, S lesions and prognosis. These results provide a strong basis for guiding IgAN patients to choose treatment based on the characteristics of renal disease.