移植肾IgA肾病临床病理及预后分析  

Clinical pathology and prognosis of allograft IgA nephropathy

作　　者：王苏娅 苏日古嘎 吕军好[1] 王慧萍 吴建永 彭文瀚[1,2,3] 王仁定 黄洪锋[1,2,3] 陈江华 Wang Suya;Suri Guga;Lyu Junhao;Wang Huiping;Wu Jianyong;Peng Wenhan;Wang Rending;Huang Hongfeng;Chen Jianghua(Kidney Disease Center,the First Affiliated Hospital,College of Medicine,Zhejiang University,Hangzhou 310003,China;Key Laboratory of Kidney Disease Prevention and Control Technology,Hangzhou 310003,China;Institute of Nephrology,Zhejiang University,Hangzhou 310003,China)

机构地区：[1]浙江大学医学院附属第一医院肾脏病中心,杭州310003 [2]浙江省肾脏病防治技术研究重点实验室,杭州310003 [3]浙江大学肾脏病研究所,杭州310003

出　　处：《中华肾脏病杂志》2020年第4期286-293,共8页Chinese Journal of Nephrology

基　　金：国家自然科学基金(81770752)。

摘　　要：目的探讨移植肾IgA肾病(IgAN)复发或新发的诱因及移植肾生存的危险因素。方法选取2012年11月至2018年12月浙江大学医学院附属第一医院经肾活检确诊为移植肾IgAN的患者,按照血肌酐(Scr)增高水平、估算肾小球滤过率(eGFR)下降率分为稳定组(Scr升高值<20μmol/L,eGFR下降率<10%)和进展组(Scr增高但未达翻倍值,30%<eGFR下降率<60%),以及根据血肌酐翻倍、eGFR<15 ml·min-1·(1.73 m2)-1至慢性肾脏病5期设为失功组。回顾性分析和比较3组移植肾IgAN患者肾脏病理改变及临床特征。以eGFR<15 ml·min-1·(1.73 m2)-1至慢性肾脏病5期为随访终点事件,采用Kaplan-Meier生存曲线分析他克莫司(FK506)血浓度、尿蛋白和移植肾病理改变对移植肾生存率的影响。结果38例移植肾IgAN患者肾活检时尿蛋白/肌酐比值(UP/Cr)为(2.00±2.38)g/g,17例(44.7%)患者血肌酐增高,29例应用FK506患者中16例(55.2%)发病前FK506血浓度<4μg/L。肾活检术后随访(23.2±22.2)个月,11例(28.9%)患者肾功能不全进展(进展组),7例(18.4%)移植肾失功(失功组)。失功组患者UP/Cr显著高于稳定组(P=0.001),肾穿前FK506血浓度显著低于稳定组[(3.05±0.71)μg/L比(5.03±1.62)μg/L,P=0.010]。Kaplan-Meier生存分析结果显示,FK506低浓度(<4.0μg/L)、大量蛋白尿患者的移植肾生存率分别显著低于FK506血浓度≥4.0μg/L、UP/Cr<2.3 g/g患者(分别P=0.020,P=0.001);肾小球毛细血管袢内有炎细胞浸润和系膜区C1q沉积患者的移植肾生存率显著低于毛细血管袢内无炎细胞浸润和系膜区无C1q沉积患者(分别P=0.042,P=0.015)。结论FK506低浓度是移植肾IgAN复发或新发的诱因。大量蛋白尿、肾小球毛细血管袢内炎细胞浸润、系膜区C1q沉积以及FK506低浓度是移植肾生存率的影响因素。Objective To investigate the cause of the allograft IgA nephropathy(IgAN)recurrence or de novo,and the risk factors for the graft-survival in allograft IgAN.Methods Patients from the First Affiliated Hospital of Zhejiang University Medical College who were diagnosed as a transplanted kidney IgAN by allo-renal biopsy during November 2012 to December 2018 were selected.According to the increased levels of serum creatinine and the descent rate of estimated glomerular filtration rate(eGFR)on the last follow up,the patients were divided into the graft-function stable group(increased Scr<20μmol/L,eGFR descent rate<10%),the graft-function inadequacy progressive group(Scr increased but less than doubling increase,30%<eGFR descent rate<60%)and the graft-function lost group[double increase in serum creatinine and eGFR down to<15 ml·min-1·(1.73 m2)-1 to chronic kidney disease stage V].The clinical data and pathological characteristics were retrospectively analyzed and compared in the three groups.Taking the eGFR drop to<15 ml·min-1·(1.73 m2)-1 to chronic kidney disease stage V as the end point event of follow-up,the effects of tacrolimus(FK506)concentration,the quantity of proteinuria and pathological changes of graft-renal on the survival rate of graft-renal were analyzed by Kaplan-Meier survival curve.Results At the time of allograft biopsy,the urine protein/creatinine ratio(UP/Cr)was(2.00±2.38)g/g in the 38 cases,and the serum creatine increased in 17 cases(44.7%).Meanwhile,the blood concentration of FK506 was<4μg/L in 16 of 29(55.2%)cases who taken FK506.With(23.2±22.2)months follow-up after renal biopsy,11 cases(28.9%)progressed in renal insufficiency(graft-function inadequacy progressive group),and 7 cases(18.4%)lost their graft-function(graft-function lost group).The UP/Cr on the biopsy was significantly higher in graft-function lost group than that in graft-function stable group(P=0.001),and the blood concentration of tacrolimus before biopsy was significantly lower in graft-function lost group than that in

关 键 词：肾小球肾炎 IgA 肾移植 病理 临床 普乐可复 

分 类 号：R699[医药卫生—泌尿科学] R692[医药卫生—外科学]