伴与不伴原发性肾病的恶性高血压肾损害临床病理特点及预后对比分析  

Comparative analysis of clinico-pathological characteristics and outcomes in malignant hypertension patients with and without primary glomerular diseases

作　　者：陈天新[1] 陈波[1] 陈薪薪[1] 周莹[1] 李铎[1] 丁晓凯[1] 赵润英 缪初升[3] 陈朝生[1] Chen Tianxin;Chen Bo;Chen Xinxin;Zhou Ying;Li Duo;Ding Xiaokai;Zhao Runying;Miao Chusheng;Chen Chaosheng(Department of Nephrology,the First Affiliated Hospital of Wenzhou Medical University,Wenzhou 325000,China;Department of Nephrology,Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine,Wenzhou 325000,China;Department of Nephrology,Ruian Municipal Hospital,Ruian City of Zhejiang Province,Ruian 325000,China)

机构地区：[1]温州医科大学附属第一医院肾内科,温州325000 [2]浙江省温州市中西医结合医院肾内科,温州325000 [3]浙江省瑞安市人民医院肾内科,瑞安325000

出　　处：《中华肾脏病杂志》2019年第12期906-913,共8页Chinese Journal of Nephrology

基　　金：浙江省自然科学基金(LY15H050008);温州市科技计划项目(Y20140689)。

摘　　要：目的研究恶性高血压伴和不伴原发性肾病患者的临床病理特点和预后以及其影响因素。方法回顾性分析2010年1月至2018年12月临床诊断为恶性高血压、肾病理证实为恶性高血压肾损害且具有完整临床病例资料的患者。根据临床和肾脏病理将患者分为恶性高血压肾损害无原发性肾病患者(恶高组)和伴有原发性肾病患者(恶高肾病组)。收集住院临床基线资料及随访资料,分析比较两组患者的临床病理特征和预后以及其影响因素。结果共有31例住院患者入选,其中恶高肾病组18例,年龄(32.5±6.5)岁,男性12例,原发性IgA肾病比例较高(16/18);恶高组13例,年龄(34.7±8.1)岁,男性12例。恶高肾病组血浆白蛋白明显低于恶高组[(32.7±6.4)g/L比(38.5±7.3)g/L,P=0.027],24 h尿蛋白明显高于恶高组[(4.03±2.71)g比(1.45±0.98)g,P=0.002],临床非均一性血尿发生比例明显高于恶高组(14/18比0,P=0.001)。恶高肾病组球性硬化数、球性硬化比率≥50%患者的比例、系膜细胞增生和新月体患者比例均明显高于恶高组(均P<0.05),但肾小球毛细血管袢缺血性皱缩比例明显低于恶高组(P<0.01),重度肾小管萎缩/间质纤维化患者比例明显高于恶高组(P<0.01)。两组患者肾小血管和微血管的急性损伤和慢性病变发生比例差异无统计学意义。Cox回归分析发现,只有急性肾小管损伤(刷状缘脱落、小管上皮细胞扁平化)是肾功能好转的预测因素(HR=5.956,95%CI 1.198~29.614,P=0.029)。以终末期肾病(ESRD)为研究终点,Kaplan-Meier生存分析显示,恶高肾病组的肾脏累计存活时间明显短于恶高组[(24.1±9.3)个月比(56.6±12.4)个月],肾脏累积存活率明显低于恶高组(11.6%比53.3%,Log-rank χ^2=5.022,P=0.025)。多因素Cox回归分析发现,重度肾小管萎缩/间质纤维化是恶性高血压患者进展至ESRD的风险因素(HR=5.870,95% CI 1.372~25.112,P=0.017)。结论恶性高血压伴有原发性肾病比不伴�Objective To investigate the clinico-pathological characteristics,outcomes and their predictors in malignant hypertension related kidney injury with and without primary glomerular diseases.Methods Patients with clinical diagnosis of malignant hypertension,biopsy-proven kidney injury caused by malignant hypertension and complete clinical data from January 2010 to December 2018 were retrospectively analyzed.According to clinical and renal pathology,patients were divided into malignant hypertension related kidney injury without primary nephropathy group and with primary nephropathy group.Clinico-pathological characteristics and outcomes were evaluated and compared between malignant hypertension related kidney injury with and without primary glomerular diseases.Results Totally 31 biopsy-proven kidney injury patients were analyzed.Among them,there were 18 cases with primary glomerular diseases and 13 cases without primary glomerular diseases,with age of(32.5±6.5)years old and(34.7±8.1)years old,respectively.There were 12 males in both group.The proportion of primary IgA nephropathy was higher(16/18)in the group of malignant hypertension related kidney injury with primary glomerular diseases.Malignant hypertension with primary glomerular diseases patients had lower plasma albunin level[(32.7±6.4)g/L vs(38.5±7.3)g/L,P=0.027],higher 24-hour proteinuria level[(4.03±2.71)g vs(1.45±0.98)g,P=0.002]and higher incidence rates of dysmorphic hematuria(14/18 vs 0,P=0.001)than those without primary glomerular diseases patients.Glomerular sclerosis,mesangial proliferation,tubular atrophy and interstitial fibrosis were more severe in malignant hypertension with primary glomerular diseases patients(all P<0.05),but the ischemic wrinkling of glomerular capillary was more severe in malignant hypertension without primary glomerular diseases(P<0.01).There were no differences of acute or chronic malignant hypertensive injury in small artery and in afferent arterioles between the two groups.Cox regression analysis showed that loss of

关 键 词：高血压 病理学 临床 预后 活组织检查 肾小球硬化 终末期肾病 

分 类 号：R73[医药卫生—肿瘤]