他克莫司与霉酚酸酯治疗儿童难治性IgA肾病的疗效比较  

Comparison of tacrolimus and mycophenolate mofetil in the treatment of refractory IgA nephropathy children

作　　者：吴和燕 高春林 方香 张沛 杨晓 夏正坤 Wu Heyan;Gao Chunlin;Fang Xiang;Zhang Pei;Yang Xiao;Xia Zhengkun(Department of Pediatrics,Jinling Hospital,the First School of Clinical Medicine,Southern Medical University,Nanjing 210002,China)

机构地区：[1]南方医科大学第一临床医学院(东部战区总医院)儿科,南京210002

出　　处：《中华肾脏病杂志》2020年第4期264-270,共7页Chinese Journal of Nephrology

基　　金：江苏省重点研发计划-临床前沿技术项目(BE2017719);江苏省儿科医学创新团队项目(CXTDA2017022)。

摘　　要：目的比较他克莫司(tacrolimus,TAC)与霉酚酸酯(mycophenolate mofetil,MMF)在难治性IgA肾病(IgA nephropathy,IgAN)患儿的临床疗效。方法难治性IgAN的诊断定义为:在联合肾素-血管紧张素系统(RAS)阻断剂及糖皮质激素序贯治疗后,仍表现为大量蛋白尿(≥50 mg·kg-1·d-1)。遵循病例对照匹配方法,回顾性选取2012年1月1日至2016年12月31日在东部战区总医院行肾活检确诊为难治性IgAN的患儿76例,根据治疗方案将患儿分为TAC组(38例)和MMF组(38例),比较两组24 h尿蛋白量(24hUP)、血清白蛋白(Alb)、血清肌酐(Scr)、血清尿酸(UA)、血糖(Glu)、不良反应发生情况以及疗效等。结果两组患者间年龄、性别比、血压、估算肾小球滤过率(eGFR)、24hUP、尿红细胞计数(U-RBC)、Scr、Alb、BUN、天门冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT)、Glu及病理牛津分型、加用免疫抑制剂前行大剂量甲泼尼龙冲击治疗比例差异均无统计学意义(均P>0.05),两组患者具有可比性。用药3个月起,两组患儿24hUP均较基线值明显降低,差异有统计学意义(均P<0.05),且在3、6、12个月时TAC组24hUP均显著低于MMF组(均P<0.05)。TAC组Alb在用药1个月后即较基线值明显升高(P<0.05),而MMF组在用药3个月后明显升高(P<0.05),其中TAC组Alb在1、3、6个月时均高于MMF组(均P<0.05),在12个月时两组Alb差异无统计学意义。TAC组的总有效率、完全缓解率及无效率自用药3个月起与MMF组差异均有统计学意义(均P<0.05),但随访期间部分缓解率、随访时点复发率及累计复发率两组间差异无统计学意义(均P>0.05)。其中TAC组在6个月时达到最大有效率(94.7%),而MMF组在12个月时达到最大有效率(68.4%),差异有统计学意义(χ2=8.756,P=0.003)。两组不良反应发生率比较差异无统计学意义(15.8%比21.1%,χ2=0.350,P=0.554)。但TAC组在治疗3个月时血糖高于MMF组,差异有统计学意义[5.02(4.72,5.22)mmol/L比4.42(4.19,5.07)mmol/LObjective To observe the clinical efficacy of tacrolimus(TAC)and mycophenolate mofetil(MMF)in children with refractory IgA nephropathy(IgAN).Methods The diagnosis of refractory IgAN was defined as urinary protein level≥50 mg·kg-1·d-1 after treatment with renin-angiotensin system(RAS)blocker and prednisone.Following the case-control matching method,76 children with renal biopsy diagnosed as refractory IgAN in the Jinling Hospital from January 1,2012 to December 31,2016 were retrospectively selected,and the children were divided into TAC group(38 cases)and MMF group(38 cases).The 24 h urinary protein quantity(24hUP),serum albumin(Alb),serum creatinine(Scr),serum uric acid(UA),serum glucose(Glu),adverse reactions and treatment effects were compared between the two groups.Results There were no significant differences in the age,sex ratio,blood pressure,estimated glomerular filtration rate(eGFR),24hUP,urine red blood cell count(U-RBC),Scr,Alb,BUN,aspartate transarninase(AST),alanine transarninase(ALT),Glu,pathological Oxford classification,and the proportions of big-dose methylprednisolone treatment before using immunosuppressants between the two groups(all P>0.05),and they were comparable.From 3 months after treatment,the 24hUP levels of the two groups were significantly lower than those of the baseline(all P<0.05),and the 24hUP levels of TAC group were lower than those of MMF group at 3,6 and 12 months(all P<0.05).The Alb level of TAC group was significantly higher than the baseline value from 1 month of treatment(P<0.05),while the Alb level in the MMF group was significantly higher from 3 months of treatment(P<0.05).The Alb levels in the TAC group were higher than those in MMF group after 1,3,and 6 month of treatment(all P<0.05),and there was no significant difference in Alb level at 12 months between the two groups.The total effective rate,complete remission rate and ineffectiveness rate of the TAC group all showed significant differences with the MMF group from 3 month of treatment(all P<0.05),but there was n

关 键 词：他罗利姆 霉酚酸 肾小球肾炎 IgA 儿童 

分 类 号：R726[医药卫生—儿科]