糖皮质激素联合免疫抑制剂治疗特发性膜性肾病的疗效分析  

Effect of steroids combined with immunosuppressant on idiopathic membranous nephropathy

作　　者：徐丽梨[1] 吴晓静[1] 李欣[1] 张暮寅[1] 李灏[1] 郝旭[1] 乔盼盼[1] 王伟铭[1] XU Lili;WU Xiaojing;LI Xin;ZHANG Muyin;LI Hao;HAO Xu;QIAO Panpan;WANG Weiming(Department of Nephrology,Ruijin Hospital North Branch,Shanghai Jiao Tong University School of Medicine,Shanghai 201800,China)

机构地区：[1]上海交通大学医学院附属瑞金医院(北部院区)肾内科,上海201800

出　　处：《上海医学》2021年第11期817-821,共5页Shanghai Medical Journal

摘　　要：目的分析糖皮质激素联合免疫抑制剂治疗特发性膜性肾病(IMN)的疗效。方法收集2014年6月—2019年12月在上海交通大学医学院附属瑞金医院(北部院区)就诊并经肾脏穿刺活组织检查(简称活检)确诊的95例IMN患者的临床资料,其中糖皮质激素联合环磷酰胺(CTX)组62例,糖皮质激素联合环孢素A(CsA)组33例,分析不同方案对IMN的疗效。结果糖皮质激素联合CsA组与糖皮质激素联合CTX组患者的年龄及基线估算肾小球滤过率(eGFR)水平的差异均有统计学意义(P值均<0.05)。在糖皮质激素联合CTX组的62例患者中,57例完成随访,5例随访6个月后失访;糖皮质激素联合CsA组33例患者均完成随访。对糖皮质激素联合CsA组与糖皮质激素联合CTX组患者随访观察9个月,与基线值相比,两组方案都可使IMN患者24 h尿蛋白定量显著降低,血清白蛋白水平显著升高(P值均<0.05)。糖皮质激素联合CsA组随访3个月和6个月时,患者的完全缓解(CR)或部分缓解(PR)率(即总体缓解率)均显著高于糖皮质激素联合CTX组[3个月:60.1%(20/33)比38.6%(22/57)。6个月:87.9%(29/33)比63.2%(36/57)。P值均<0.05]。随访9个月时,糖皮质激素联合CsA组CR率显著高于糖皮质激素联合CTX组[69.7%(23/33)比47.4%(27/57),P<0.05]。与基线值相比,糖皮质激素联合CsA组患者血清肌酐水平显著升高,eGFR每年下降预计25.3 mL/(min·1.73 m^(2))(P值均<0.05);糖皮质激素联合CTX组患者肾功能均未受显著影响(P值均>0.05)。随访9个月后,糖皮质激素联合CsA组有6例CR或PR患者在减药过程中或停药后复发,复发率为21.4%(6/28)。糖皮质激素联合CTX组有2例CR或PR患者停药后复发,复发率为5.0%(2/40)。结论糖皮质激素联合CsA较糖皮质激素联合CTX治疗IMN起效快,总体疗效相当,但复发率高,对肾功能有一定影响。Objective To evaluate the efficacy of steroids plus immunosuppressant in idiopathic membranous nephropathy(IMN).Methods A total of 95 patients admitted to Ruijin Hospital North Branch,Shanghai Jiao Tong University School of Medicine and diagnosed as IMN by renal biopsy between June 2014 and December 2019 were enrolled in this study.Of them,62 patients were treated by oral steroids plus cyclophosphamide(GC+CTX group)and 33 were treated by oral steroids plus cyclosporine A(GC+CsA group).Clinical outcomes were compared between the two groups.Results There were statistical differences in age and baseline eGFR level between the two groups(both P<0.05).Five patients of GC+CTX group dropped out and the other patients completed follow-up.Compared with baseline,24-hour urinary protein was significantly decreased and serum albumin level was significantly increased in in both groups after 9 months of follow-up(P<0.05).The complete remission(CR)or partial remission(PR)rate at 3 months and 6 months of follow-up in GC+CsA group were significantly higher than that in GC+CTX group(60.1%[20/33]vs.38.6%[22/57],87.9%[29/33]vs.63.2%[36/57],respectively,both P<0.05).At 9 months of follow-up,the CR rate in GC+CsA group was significantly higher than that in GC+CTX group(69.7%[23/33]vs.47.4%[27/57],P<0.05).Compared with baseline,serum creatinine level was significantly increased and eGFR decreased by 25.3 mL/(min·1.73 m^(2))per year in the GC+CsA group(both P<0.05),while renal function was not significantly affected in GC+CTX group(both P>0.05).After 9 months of follow-up,the relapse appeared in 6(21.4%,6/28)CR or PR patients after withdrawal of CG+CsA and in 2(5.0%,2/40)CR or PR patients after withdrawal of GC+CTX.Conclusion GC+CsA and GC+CTX has similar overall curative effect in treatment of IMN.But GC+CsA have faster effects,higher recurrence rate and obvious renal damage.

关 键 词：肾小球肾炎 膜性 钙调磷酸酶抑制剂 环磷酰胺 环孢菌素 泼尼松 随访研究 预后 复发 

分 类 号：R692[医药卫生—泌尿科学]