腹膜透析治疗急进性肾炎综合征患者的临床分析

目的分析用腹膜透析(PD)治疗并脱离透析的急进性肾炎(RPGN)综合征患者的临床表现特点及预后。方法回顾性分析2009年2月至2018年8月在浙江大学医学院附属第一医院肾脏病中心诊断并接受PD治疗的RPGN患者临床资料,入选者原发病因包括狼疮肾炎、抗中性粒细胞胞质抗体(ANCA)相关性血管炎及原发性肾小球肾炎,所有入选者均脱离透析及肾功能恢复。按照脱离透析时间分为早期脱离透析组(维持PD时间≤183 d)和晚期脱离透析组(维持PD时间>183 d)。比较两组患者进入透析时和脱离透析时临床指标的差异。采用Kaplan-Meier曲线分析两组患者累积不良事件发生率的差异,Cox比例风险模型分析患者预后不良的危险因素。结果48例RPGN患者被纳入本研究,患者维持透析时间中位数为178(76,378)d。与晚期脱离透析组比较,早期脱离透析组患者进入透析时的尿量、血清白蛋白、全段甲状旁腺激素水平较低;肉眼血尿及合并高血压占比亦较低(均P<0.05)。早期脱离透析组患者脱离透析时血肌酐、血钙、血白蛋白及全段甲状旁腺激素水平显著低于晚期脱离透析组,采用激素冲击、联合免疫抑制剂治疗及用血液透析过渡等治疗措施的占比高于晚期脱离透析组(均P<0.05)。Kaplan-Meier生存曲线分析结果显示,两组患者累积不良预后发生率的差异无统计学意义(Log-rank检验χ^2=3.485,P=0.062)。Cox回归分析结果显示,脱离透析时血肌酐≥209μmol/L是患者预后不良的独立危险因素(HR=5.253,95%CI 1.757~15.702,P=0.003)。结论PD可用于狼疮肾炎、ANCA相关性血管炎和原发性肾小球肾炎所致RPGN患者的治疗。脱离透析时血肌酐≥209μmol/L是RPGN患者预后不良的独立危险因素。

Clinical analysis of peritoneal dialysis in the treatment of rapidly progressive glomerulonephritis

Objective To observe the clinical characteristics and prognosis of patients with rapidly progressive glomerulonephritis (RPGN) caused by lupus nephritis, antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, or primary glomerulonephritis who were treated with peritoneal dialysis (PD) and then withdrew PD because of renal recovery. Methods Data of the above patients were retrospectively analyzed. The patients were diagnosed as RPGN and received PD therapy in Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University from February 2009 to August 2018. The patients were divided into early withdrawal group (PD time≤183 days, n=24) and late withdrawal group (PD time＞183 day, n=24). The differences of clinical characteristics between the two groups were compared. The cumulative incidence of adverse events in both groups was analyzed using Kaplan-Meier curves. Cox proportional hazards model was used to analyze the risk factors influencing the prognosis of patients. Results Forty-eight RPGN patients were included. The median time of maintaining PD was 178(76, 378) days. Compared with the late withdrawal group, the patients in early withdrawal group had lower levels of urine volume, serum albumin and parathyroid hormone, and lower rates of gross hematuria and hypertension at the beginning of PD, and received higher rates of methylprednisolone impulse, combined immunosuppressive agents, and hemodialysis or continuous renal replacement therapy (all P＜0.05). At the time of PD withdrawal, the levels of serum creatinine, serum calcium, serum albumin and parathyroid hormone in the early withdrawal group were significantly lower than those in the late withdrawal group (all P＜0.05). The Kaplan-Meier curves showed that there was no significant difference in the cumulative survival of patients in both groups (log-rank test χ2=3.485, P=0.062). Cox regression analysis revealed serum creatinine≥209 μmol/L at the time of PD withdrawal was an independent risk factor for poor prognosis (HR=5.253，95%CI 1.757-15.702, P=0.003). Conclusions PD can be used for RPGN patients caused by lupus nephritis, ANCA-associated vasculitis and primary nephritis. Serum creatinine≥209 μmol/L at the time of PD withdrawal is an independent risk factor for poor prognosis.