低剂量免疫抑制剂治疗轻中症ANCA相关性肾血管炎的效果和肾脏预后分析  

Analysis of the efficacy and renal prognosis of reduced-dose immunosuppressive regimen in patients with mild to moderate ANCA-associated renal vasculitis

作　　者：李子扬 包继文 尧欢珍 张敏芳[1] 顾乐怡[1] 倪兆慧[1] 王玲[1] Ziyang Li;Jiwen Bao;Huanzhen Yao;Minfang Zhang;Leyi Gu;Zhaohui Ni;Ling Wang(Department of Nephrology,Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200120,China)

机构地区：[1]上海交通大学医学院附属仁济医院肾脏科,200120

出　　处：《中华肾病研究电子杂志》2022年第5期241-248,共8页Chinese Journal of Kidney Disease Investigation（Electronic Edition）

摘　　要：目的高剂量免疫抑制剂治疗导致的继发感染是ANCA相关性血管炎患者最常见的死亡原因,本研究旨在探索低剂量的免疫抑制剂治疗是否可以在减少轻中症ANCA相关性肾血管炎患者继发感染的同时达到有效缓解,并分析治疗早期继发感染是否会加速肾功能的恶化。方法使用Fisher精确概率法比较初始糖皮质激素减量联合低频次静脉冲击环磷酰胺与标准方案的疗效及安全性差异;使用Kaplan-Meier生存曲线和Log-rank检验比较各因素影响下的肾脏存活率,将其中P<0.05的因素纳入多因素Cox风险回归模型以确定导致终末期肾病(ESRD)的危险因素,再使用受试者工作特征(ROC)曲线评价该危险因素的敏感性和特异性。结果最终纳入58例患者,其中标准方案组35例、初始糖皮质激素减量组23例。纳入患者的平均年龄是(62.45±12.70)岁,平均基线血肌酐水平是251.35μmol/L。24个月内有9例(15.52%)进展为ESRD(标准方案组7例,初始糖皮质激素减量组2例,P=0.21),治疗3个月后有10例发生继发感染(标准方案组9例,初始糖皮质激素减量组1例,P=0.035)。多因素Cox风险回归模型显示:基线血肌酐(HR1.01,95%CI:1.001~1.014,P=0.014)、初治3个月内继发感染(HR9.83,95%CI:2.14~45.27,P=0.003)、接受治疗后持续性血尿超过6个月(HR5.60,95%CI:1.36~23.18,P=0.017)是ANCA相关性肾血管炎患者进展为ESRD的危险因素。结论对轻中症ANCA相关性肾血管炎患者,初始糖皮质激素减量联合低频次静脉冲击环磷酰胺方案可明显降低继发感染率,且疗效不弱于标准方案。初治3个月内继发感染的患者早期进展为ESRD的风险更高。Objective Secondary infection caused by high-dose immunosuppressive therapy is the most common cause of death in patients with ANCA-associated vasculitis.This study aimed to explore whether reduced-dose of immunosuppressive therapy could achieve effective remission together with less secondary infection in patients with mild to moderate ANCA-associated renal vasculitis,and to determine whether early secondary infections could accelerate the deterioration of renal function.MethodsThe efficacy and safety of reduced-dose regimen and standard regimen were compared with Fisher′s precision probability test.The renal survival rate was estimated with the Kaplan-Meier method and compared with the log-rank test.Potential variates were examined by means of the multivariate Cox hazard regression model to determine the risk factors of end-stage renal disease,while the receiver operating characteristic(ROC)curve was applied to evaluate the sensitivity and specificity of the risk factors.ResultsA total of 58 patients were included,with 35 patients in the standard-dose glucocorticoids group and 23 in the reduced-dose glucocorticoids group.The average age of the included patients was 62.45±12.70 years,and the baseline serum creatinine was 251.35μmol/L.9 patients(15.52%)developed end-stage renal disease(ESRD)within 24 months(7 from the standard regimen group and 2 from the reduced-dose regemen group,P=0.21).10 patients developed secondary infection 3 months after treatment(9 from the standard regimen group and 1 from the reduced-dose regemen group,P=0.035).Multivariate Cox regression model analysis displayed that the baseline serum creatinine(HR0.007,95%CI:2.48-39.48,P=0.014),secondary infection rate within first 3 months(HR2.28,95%CI:2.14-45.27,P=0.003),and persistent hematuria for more than 6 months(HR1.723,95%CI:0.043-0.738,P=0.017)were risk factors of ESRD in patients with ANCA-associated renal vasculitis.ConclusionThe regimen of initial reduced-dose immunosuppressive therapy could significantly reduce the secondary infect

关 键 词：ANCA相关性肾血管炎 终末期肾病 继发感染 减量糖皮质激素 环磷酰胺低频次静脉冲击 

分 类 号：R59[医药卫生—内科学]