肾小管周毛细血管损伤与原发高血压恶性肾硬化患者临床及长期预后的关系  

Peritubular capillaries injury and its association with clinical characteristics and long term renal survival in primary malignant nephrosclerosis patients

作　　者：夏鹏[1] 郎珈馨 文煜冰[1] 施潇潇[1] 王海云[1] 郑可[1] 叶葳[1] 蔡建芳[1] 叶文玲[1] 于阳[1] 李航[1] 李明喜[1] 李雪梅[1] 李学旺[1] 陈丽萌[1] 

机构地区：[1]中国医学科学院北京协和医院肾内科,北京100730

出　　处：《中华肾脏病杂志》2017年第9期641-648,共8页Chinese Journal of Nephrology

基　　金：基金项目：国家自然科学基金（81170674、81470937、81641024）;中国医学科学院医学与健康科技创新工程（2016.12M.2.004）;中国医学科学院协和学者基金

摘　　要：目的探讨原发性高血压恶性肾硬化患者的临床病理特点、肾小管周毛细血管（pefitubular capillary，PTC）损伤情况及肾脏长期预后的影响因素。方法纳入2003年1月1日至2012年3月30日在北京协和医院经肾脏病理诊断的恶性肾硬化（MN）患者52例，获取临床病理资料并进行随访，对肾活检标本进行CD34染色，对照组为良性肾硬化（BN，17例）和肾小球轻微病变患者（GML，19例），Cox回归分析影响患者长期预后的危险因素。结果52例原发性高血压恶性肾硬化患者的男女比例为12：1，平均年龄（34．0±8．2）岁。收缩压最高（230．4±25．0）mmHg，舒张压最高为（156．4±20．6）mmHg，伴有不同程度肾功能损害和蛋白尿。肾脏病理中。肾小球硬化指数、肾小管萎缩、间质纤维化的程度与eGFR和尿蛋白水平相关（P〈0．01）。经过有效降压治疗，血压达标率显著提高（76．9％比3．7％，P〈0．01）；血肌酐显著降低[（376．4±263．8）μmol／L比（486．8±375．7）μmol／L，秩和检验P〈0．01]，24h尿蛋白量显著改善[（1．10±0．70）g比（2．04±1．26）g，P〈0．01，n=211。恶性肾硬化组肾脏PTC面积比例显著低于BN组和GML组，并与Scr（r=-0．553，P=0．001）、eGFR（r=0．476，P=0．004）显著相关。中位随访74个月，1年、5年和10年的肾脏累积存活率为90％、64％和23％。Kaplan—Meier分析显示PTC面积比例较高者肾脏生存时间更长[（114．8±12．4）个月比（63．0±8．3）个月，Log．Rank检验矿：5．312，P〈0．05]。单因素Cox风险回归分析提示血压控制不达标、出院时eGFR〈30ml·min^-1·（1．73m^2）^-1、PTC面积比例低、。肾小管间质损伤重、贫血是肾脏不良预后的危险因素；多因素Cox风险回归分析提示血压控制不达标（RR=3．89，95％CI1．75—8．65，P=0．001）和出院时eGFR〈30ml·min^-1·（1．73m^2）^-1（RR=4．27，95％CObjective To analyze the clinic-pathological data and peritubular capillary （PTC） injuries of malignant nephrosclerosis （MN） patients and their correlations with the long term renal survival. Methods This was a retrospective cohort study of 52 MN patients in Peking Union Medical College Hospital from January 2003 to March 2012. Their clinical data and renal biopsy samples were carefully studied. CD34 staining was performed to evaluate the PTC area, using Benign nephrosclerosis （BN, n=17） patients and glomerular minimal lesions （GML, n=19） patients as controls. Multivariate Cox proportional hazard model was used to identify the potential independent risk factors for long term renal survival. Results Fifty-two MN patients were enrolled. The sex ratio of male to female was 12：1 and the average age was （34.0±8.2） years. The maximum blood pressure （SBP/DBP） was （230.4 ± 25.0）/（156.4 ± 20.6） mmHg, companied with significant loss of eGFR and proteinuria. Glomerular sclerosis index, tubular atrophy and interstitial fibrosis correlated with eGFR and proteinuria （P 〈 0.05）. After aggressive treatment, BP control rate improved significantly （76.9% vs 3.7%, P 〈 0.01）, Scr [（376.4±263.8） μmol/L vs （486.8±375.7） μmol/L, Wilcoxon test, P 〈 0.01] and proteinuria [（1.10±0.70） g/24 h vs （2.04±1.26） g/24 h, P 〈 0.01, n=21] also improved. PTC area in MN patients was significantly lower than those in BN patients and GML patients, and it correlated well with Scr （r=-0.553, P=0.001） and eGFR （r=0.476, P=0.004）. The median follow-up time was 74 months, the cumulative renal survival rate at 1 year, 5 year and 10 year was 90%, 64% and 23%, respectively. Kaplan-Meier analysis showed that the patients with higher PTC area had longer renal survival time [（114.8± 12.4） months vs （63.0±8.3） months, X^2=5.312, P 〈 0.05]. Univariate Cox proportional hazard model found that unsatisfied BP control, eGFR 〈 30 ml · min^-1· （1.73 m^2）^-1 upon discha

关 键 词：高血压 肾硬化 毛细血管 预后 

分 类 号：R544.11[医药卫生—心血管疾病] R692[医药卫生—内科学]