慢性肾脏病3~5期伴重度蛋白尿患者的临床病理和预后分析

 目的 分析慢性肾脏病（chronic kidney disease，CKD）3~5期伴重度蛋白尿患者的临床表现和病理改变，并随访观察患者的预后。方法 回顾性分析2005年7月至2009年2月CKD 3~5期患者174例。比较尿蛋白≥3.0 g/24 h的重度蛋白尿组（A组）及尿蛋白<3.0 g/24 h的轻、中度蛋白尿组（B组）患者的临床和病理特点、治疗疗效及随访中肾存活率。结果 A组患者与B组患者相比，肾活检时肾功能较差，进入CKD 4期及以上的比例更高（95.92% vs. 86.84%，P<0.05）。A组患者肾脏病理类型多样、复杂，但肾小管间质疾病及血管病变所致肾损伤少见。IgA肾病中，A组患者的肾脏病理活动性病变较B组更为严重。经糖皮质激素或免疫抑制剂治疗后，A组患者尿蛋白较治疗前显著下降［（2.77±1.98）vs.（6.21±3.37）g/24 h，P<0.01］，血白蛋白水平升高［（38.73±5.86）vs.（31.42±7.63）g/L，P<0.01］，肾小球滤过率升高［（34.69±26.35）vs.（20.25±6.87）mL·min^-1·1.73 m^-2，P<0.01］，肾功能改善，但肾存活率低于B组（50.75% vs. 70.83%，P<0.05）。结论 CKD 3~5期伴重度蛋白尿患者与伴轻、中度蛋白尿患者相比，肾功能更差，病理上活动性病变更明显，肾存活率更低；激素及免疫抑制剂治疗可使部分患者的尿蛋白减少，改善肾功能。CKD 3~5期患者仍需行肾活检以便明确诊断、及时治疗。

Clinical features and prognostic analysis of chronic kidney disease stage 3-5 with massive proteinuria

Objective To analyze the clinicopathological features and prognosis of stage 3-5 chronic kidney disease (CKD) with massive proteinuria. Methods This retrospective study analyzed the presenting features, renal histology and outcome of 174 stage 3-5 CKD patients compare the difference between patients with massive proteinuria (proteinuria≥3.0 g/24 h, group A) and patients without massive proteinuria (proteinuria<3.0 g/24 h, group B). Results Compared with group B, there were more patients with stage 4-5 CKD in group A (95.92% vs. 86.84%, P<0.05) when renal biopsy. Most patients in group A were glomerulonephritis, while few were tubulointerstitial disease and vascular disease. IgA nephritis patients with massive proteinuria had more active lesions. After glucocorticoid or immunosuppressant treatment, 24 h proteinuria in group A was decreased ［post-therapy vs. pre-therapy: (2.77±1.98) vs. (6.21±3.37)g/24 h, P<0.01］, serum albumin increased ［post-therapy vs. pre-therapy: (38.73±5.86) vs. (31.42±7.63) g/L, P<0.01］, estimated glomerular filtration rate (eGFR) improved ［post-therapy vs. pre-therapy: (34.69±26.35) vs. (20.25±6.87) mL·min^-1·1.73 m^-2, P<0.01］. Kidney survival of group A was lower (50.75% vs. 70.83%, P<0.05). Conclusions Stage 3-5 CKD patients need renal biopsy to definite pathological diagnosis when conditions permit. Stage 3-5 CKD patients with massive proteinuria had different clinical presenting features, different pathologic type, more active histological lesions and poorer renal survival rate compare with those without massive proteinuria. Glucocorticoid and immunosuppressant treatment can reduce urokinase protein and improve renal function in renal functionsome patients. Renal biopsy is also necessary for the diagnosis.