中等量蛋白尿IgA肾病糖皮质激素与雷公藤治疗对比观察

目的：观察中等量短程糖皮质激素和常规剂量雷公藤多苷在中等量蛋白尿IgA肾病患者治疗中的作用,比较两组治疗蛋白尿的临床有效率。方法：患者均为临床和病理确诊的IgA肾病,24h尿蛋白定量在1-3.5g,血清肌酐正常或轻度升高（〈177μmol/L）,病理诊断符合Hass分型标准（Ⅰ-Ⅱ型）,分为激素组和雷公藤组,两组分别给予中等量短程糖皮质激素（参照意大利方案）和常规剂量雷公藤多苷（1mg·kg^-1·d^-1）治疗6个月,同时给予降血压等治疗。完成治疗及随访共59例,观察两组治疗前后的24h尿蛋白定量变化以及肾功能等指标,以尿蛋白定量减少程度作为是否有效指标,进行统计学的分析。结果：6个月后,两组患者的蛋白尿治疗有效率（尿蛋白减少〉50%）分别为59.4%和44.4%,但无统计学差异;病理类型为Ⅰ型的患者治疗有效率分别为66.7%和43.8%,病理类型为Ⅱ型的患者治疗有效率分别为50.0%和45.5%,均无统计学差异。结论：对于诊断明确的中等量蛋白尿、肾功能正常或基本正常且肾脏病理为Ⅰ-Ⅱ型（Hass分型）的IgA肾病患者,采用中等量短程糖皮质激素或常规剂量的雷公藤多苷治疗均有一定效果,且两者在有效率方面并无统计学差异。     

单纯糖皮质激素治疗IgA肾病的系统评价

目的:应用系统评价的方法探讨单纯糖皮质激素对Ig A肾病(Ig A nephropathy,IgAN)的疗效及安全性。方法:采用计算机检索Chinese Biomedical Database、EMBASE、Cochrane Library、PubMed、MEDLINE、万方、CNKI等文献数据库,收集1966年01月~2018年12月国内外单纯GC治疗IgAN的随机对照研究(randomized controlled trial,RCT)。由两名评价者独立阅读摘要和全文,评价研究质量并独立进行数据提取。采用相对危险度(relative risk,RR)、标准化均数差(standard mean difference,SMD)及95%可信区间(95%CI)描述效应量,用Stata15.0软件对结果进行统计和分析。结果:共纳入11篇文献,包括952例IgAN患者(激素组483例,对照组469例)。meta分析(meta-analysis)结果显示:(1)GC能有效降低IgAN患者蛋白尿水平,并降低IgAN患者进入终末期肾病(end-stage renal disease,ESRD)的风险;(2)泼尼松>30 mg/d(甲泼尼龙>24 mg/d)或泼尼松≤30 mg/d(甲泼尼龙≤24 mg/d)对IgAN患者的蛋白尿均有较好的疗效,但小剂量GC不能降低IgAN患者进入ESRD的风险;(3)使用不同疗程(≥1年或<1年)的GC对IgAN患者的蛋白尿均有改善作用,而仅短疗程的GC能降低IgAN患者进入ESRD的风险;(4)IgAN患者的基线eGFR水平无论是≥50 ml·min-1·1.73 m-2,还是<50 ml·min-1·1.73 m-2,GC治疗均能降低患者蛋白尿水平及进入ESRD的风险。(5)GC治疗显著增加不良反应发生的风险。结论:GC治疗IgAN蛋白尿总体疗效确切,并能有效降低IgAN患者进入ESRD的风险;不同剂量的GC均能降低IgAN的蛋白尿水平,仅有大剂量GC能有效降低患者进入ESRD的风险;GC治疗的总疗程以6~12个月为佳;GC对GFR<50 ml·min-1·1.73 m-2的Ig A肾病患者仍然有效,但应用时要更加谨慎;GC治疗中,需要密切监测其不良反应。GC为IgAN患者提供了肾脏保护,但增加了不良事件的风险,GC用于治疗IgAN的疗效和安全性需要高质量、大样本、多中心的随机对照研究进一步确定。     

福辛普利联合雷公藤多苷治疗中等量蛋白尿IgA肾病

目前IgA肾病的治疗目的主要是降低尿蛋白、防止肾脏纤维化和肾脏病变进展[1].雷公藤多苷及福辛普利用于各种IgA肾病治疗取得了较好的临床疗效[2~4],但目前尚缺乏有对照的前瞻性临床研究资料.本研究探讨雷公藤多苷及福辛普利联合应用治疗临床上以中等量蛋白尿为主要表现,病理类型为系膜增生性IgA及局灶增生性IgA肾病患者的疗效.     

小剂量糖皮质激素治疗中度蛋白尿IgA肾病的随机对照研究

目的：探讨小剂量糖皮质激素（激素）治疗中度蛋白尿IgA肾病（IgAN）的疗效及安全性。方法：将62例尿蛋白1～2 g/d的IgAN患者随机分为小剂量激素组和对照组,两组在口服缬沙坦的基础上,治疗组加用泼尼松（龙）0.5 g.kg-1.d-1治疗8周,逐渐减量,总疗程48周,并进行定期随访,比较两组尿蛋白变化,以肌酐升高30%为随访终点,观察小剂量激素对IgAN肾功能的影响。结果：与对照组相比,小剂量激素组尿蛋白明显降低,第4周达到差异有统计学意义并持续至随访结束;治疗组完全缓解率和总缓解率均高于对照组,末次随访时两组分别有0例和5例到达观察终点,Kaplan Meier分析表明,小剂量激素可保护IgAN的肾功能（Log Rank,P〈0.05）。结论：小剂量糖皮质激素可持续降低中度蛋白尿IgAN的尿蛋白水平,保护肾功能,改善IgAN患者的预后,而且副作用小,依从性高,值得临床推广。     

糖皮质激素治疗IgA肾病的进展

正IgA肾病(IgA nephropathy,IgAN)是目前我国最常见的原发性肾小球疾病,临床主要表现为发作性血尿、蛋白尿、高血压和肾功能受损等。其发病率高,除部分单纯性血尿患者预后尚可,相当一部分患者预后差,肾功能缓慢下降,超过30%的患者在发病10~20年后可进入尿毒症期[1]。在我国IgAN是导致终末期肾脏病(end stage kidney disease,ESKD)的首要原因,严     

有关IgA肾病蛋白尿治疗的进展

IgA肾病(Immunoglobulin A nephropathy,IgAN)为一免疫病理诊断名称,是一组不伴有系统性疾病,肾活检在肾小球系膜区有以IgA为主的颗粒沉积,临床以血尿为主要表现的肾小球肾炎.研究表明,有80%的IgA肾病患者伴有不同程度的蛋白尿.     

IgA肾病蛋白尿的研究进展

IgA肾病是我国慢性肾功能衰竭的主要原发性病因,蛋白尿是 IgA肾病进展和预后的独立危险因素,临床表现为少量蛋白尿和微量白蛋白尿的IgA肾病病理损伤并不轻,需要早期干预治疗。本文就IgA肾病蛋白尿的研究进展作一综述。     

糖皮质激素治疗IgA肾病的循证研究

IgA肾病（IgA nephropathy，IgAN）是当今世界上最常见的原发性肾小球疾病，是我国最常见的慢性肾脏病和慢性肾衰竭的主要原发病。自1968年法国学者Berger和Hinglais首先报告该病以来，经过近40年的研究，对该病的发生发展、诊断和治疗的认识有了很大的进展，但其发病机制仍不很清楚，因此至今为止缺乏特效的治疗手段。如何控制IgAN的进展、提高疗效，一直是临床肾脏病学工作者希望解决的科学问题。由于IgAN主要是异常的IgA在肾小球系膜沉积，导致系膜增殖、硬化、炎细胞浸润，部分患者表现为血清IgA增高和补体Q下降，临床上使用免疫调节剂取得一定的疗效，提示IgAN的发病与免疫异常有关。数十年来，人们在这一方面进行了很多有益的探索。本文就糖皮质激素治疗IgAN的临床试验研究综述如下。     

中西医三环治疗IgA肾病蛋白尿的临床研究

目的：观察中西医三环治疗IgA肾病（IgAN）蛋白尿的临床疗效及其对肾功能的影响。方法：234例患者按病理Lee氏分级进行分组,Lee氏分级〈Ⅲ级为A组,随机分为治疗组（A1组32例）和对照组（A2组35例）;Lee氏分级〉Ⅲ级为B组,随机分为治疗组（B1组102例）和对照组（B2组65例）。A1组使用中医药三环＋中医新辨证方案,A2组使用ACEI/ARB＋中医原辨证方案;B1组使用中西医结合三环（中医药三环＋中医新辨证方案＋ACEI/ARB＋免疫抑制剂）,B2组使用激素＋中医原辨证方案。观察项目包括24h尿蛋白、肾功能、血白蛋白（Alb）、肝功能、血常规、尿常规及不良反应。观察时间6～8个月。结果：A1组蛋白尿、血肌酐（Scr）及血红蛋白（Alb）的改善好于A2组,A1组的总缓解率（完全缓解率＋基本缓解率）为75%,高于A2组的48.6%（P〈0.05）;B1组降蛋白尿的速度及幅度均强于B2组,B1组的总缓解率为80.4%,高于B2组的64.6%,两组比较（P〈0.05）。且B组在治疗前肾功能已下降（Scr〉133μmol/L）18例患者,其肾功能改善的程度B1组（12例）好于B2组（6例）。结论：中西医三环治疗能有效减少IgAN患者的蛋白尿,稳定并改善肾功能。     

Hydroxychloroquine in IgA nephropathy: a systematic review

BackgroundHydroxychloroquine (HCQ) has recently been reported to be a promising and safe anti-proteinuric agent for IgA nephropathy (IgAN) patients. In the present systematic review, we aimed to summarize the evidence concerning the benefits and risks of HCQ therapy in IgAN.MethodsElectronic databases were searched for randomized, cohort, or case-control studies with IgAN biopsy-proven patients comparing the effects of HCQ with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or immunosuppression on proteinuria reduction.ResultsFive studies, one randomized and three observational, involving a total of 504 patients, were eligible for inclusion. Overall, there was a tendency of HCQ treatment to reduce proteinuria. In the studies where the control arm was supportive therapy, HCQ significantly reduced proteinuria at 6 months. However, in the studies that compared HCQ to immunosuppressive therapy, we found no difference in proteinuria reduction. HCQ had no impact on eGFR.ConclusionHCQ seems to be an efficient alternative therapy for patients with IgAN who insufficiently respond to conventional therapy. However, ethnically diverse randomized controlled studies with long-term follow-up are needed.     

Efficacy and safety of mycophenolate mofetil in treatment of IgA nephropathy: a systematic review

Objective To evaluate the efficacy and safety of mycophenolate mofetil (MMF) in treatment of IgA nephropathy. Methods The Cochrane library, PubMed, EMBASE, Wanfang Data Knowledge Service Platform, CNKI and VIP were searched from the time when the databases were established to March 31, 2018. Reports on randomized controlled trials (RCTs) on treating IgAN with MMF were collected. Data were extracted and assessed independently by three reviewers and the methodological quality of included RCTs was assessed by the Cochrane collaboration's tool for assessing risk of bias. The Meta analysis of homogeneous RCTs was managed by using Stata 12.0. Results Nine RCTs, of which two RCTs were assessed as A-level studies scoring from 4 to 7 points, six RCTs were assessed as B-level studies scoring from 2 to 3 points, and one RCT was assessed as C-level study with scores less than 2 points, were enrolled in the study. Important outcomes of this systematic review were described as follows: (1) Compared to placebo plus ACEI/ARB or ACEI/ARB monotherapy, MMF plus ACEI/ARB did not reduce the incidence of increased serum creatinine and ESRD, but increased the partial remission rate of urinary protein (OR=2.59, 95%CI 1.01-6.65, P=0.049. (2) No significant difference was detected in the efficacy of reducing urinary protein for MMF monotherapy or MMF plus glucocorticoid (GC) compared to GC monotherapy. (3) MMF showed no significant difference in the efficacy of reducing urinary protein compared to LEF or CTX, but lower incidence rate of serum creatinine increasing than that of CTX group (OR=0.21, 95%CI 0.04-1.07, P=0.043. (4) Different levels of adverse reactions occurred in each treatment group with MMF, but most symptoms were mild, and recovered gradually after reducing or withdrawing MMF. Conclusions MMF monotherapy shows a superiority in curing IgAN compared to ACEI/ARB, but no significant superiority compared to GC. MMF can replace a part of the effect of GC when used in combination with GC and can reduce the dosage of GC compared to GC monotherapy. Additionally, MMF displays no better short-term efficacy than LEF or CTX, but a better long-term efficacy and fewer side effects than CTX. And the side effects occurred in the treatment groups with MMF are mostly mild, and disappear gradually after reducing or stopping the use of the drug. MMF is a safe and effective drug for the treatment of IgAN.     

Diabetic nephropathy in Africa:A systematic review

AIM:To determine the prevalence and incidence of diabetic nephropathy in Africa.METHODS:We performed a systematic narrative review of published literature following the MOOSE Guidelines for Meta-Analysis and Systematic Reviewsof Observational Studies.We searched Pub MedMEDLINE for all articles published in English and French languages between January 1994 and July 2014 using a predefined strategy based on the combination of relevant terms and the names of each of the 54 African countries and African sub-regions to capture the largest number of studies,and hand-searched the reference lists of retrieved articles.Included studies reported on the prevalence,incidence or determinants of chronic kidney disease(CKD) in people with diabetes within African countries.RESULTS:Overall,we included 32 studies from 16 countries;two being population-based studies and the remaining being clinic-based surveys.Most of the studies(90.6%) were conducted in urban settings.Methods for assessing and classifying CKD varied widely.Measurement of urine protein was the most common method of assessing kidney damage(62.5% of studies).The overall prevalence of CKD varied from 11% to 83.7%.Incident event rates were 94.9% for proteinuria at 10 years of follow-up,34.7% for endstage renal disease at 5 years of follow-up and 18.4% for mortality from nephropathy at 20 years of followup.Duration of diabetes,blood pressure,advancing age,obesity and glucose control were the common determinants of kidney disease.CONCLUSION:The burden of CKD is important among people with diabetes in Africa.High quality data from large population-based studies with validated measures of kidney function are still needed to better capture the magnitude and characteristics of diabetic nephropathy in Africa.     

Life-threatening sepsis following treatment for haemorrhoids: a systematic review

INTRODUCTION: Haemorrhoids are a common complaint with estimates suggesting a prevalence of 4% of the adult population. Treatments such as rubber band ligation (RBL), sclerotherapy and excisional surgery have been in use for many years, and recently stapled haemorrhoidopexy, or procedure for prolapsing haemorrhoids (PPH) has gained acceptance. However, there have been consistent reports of severe sepsis, including a number of deaths. The purpose of this review was to assess the scale of the problem, and identify any predisposing factors, common presenting features, and treatment options in those who suffer these complications. RESULTS: Twenty-nine papers were identified, reporting 38 patients. Of these, 17 had undergone RBL, three had sclerotherapy, one had cryotherapy, 10 had excisional surgery and seven had PPH. Ten died as a result of their sepsis. The cases included 16 with perineal sepsis, seven with retroperitoneal gas and oedema, and six with liver abscesses. Common presenting features were urinary difficulties, fever, severe pain, septic shock and leucocytosis. Most were managed by means of surgery, although a minority survived having received conservative therapy. With the exception of two patients (one of whom was human immunodeficiency virus positive and the other had a drug-induced agranulocytosis) all were well prior to surgery. CONCLUSIONS: Although extremely uncommon, severe sepsis does occur post-treatment for haemorrhoids and all surgeons who treat such patients should be aware of the potential complications and alert to their presenting features. Early presentation without evidence of tissue necrosis may be managed conservatively, although most cases are managed by means of surgery.     

Non-steroidal anti-inflammatories and the development of analgesic nephropathy: a systematic review

Background: Analgesic nephropathy (AN) is chronic renal impairment as a direct consequence of chronic heavy analgesia ingestion. An association between non-steroidal anti-inflammatory agents and chronic kidney disease (CKD) has long been suspected. Despite ample observational data obtained in recent decades the relationship remains uncertain. This systematic review intends to summarize the available literature and to define the role of non-steroidal anti-inflammatories in the natural history of AN.

Methods: We conducted a systematic literature search for articles describing the association between non-steroidal anti-inflammatory abuse and renal insufficiency. No restriction was placed on publication date, but papers were limited to English language, observational design, and human studies.

Results: Nine articles met our inclusion criteria and were discussed in this review. This includes 5 cohort studies and 4 case–control trials, with a combined population of 12,418 study subjects and 23,877 controls. Eight of the nine reports failed to identify any increased risk of chronic renal impairment with heavy non-steroidal anti-inflammatory consumption. Study methods were heterogeneous and the overall quality of data was relatively poor.

Conclusion: A relationship between non-steroidal anti-inflammatory medicines and the development of CKD has never been proven. Based on the available scientific evidence non-steroidal anti-inflammatory agents do not appear to be implicated in the pathogenesis of AN.     

Conservative treatment of sciatica: a systematic review

Most patients with sciatica (often caused by disc herniations) are managed conservatively at first. The natural course seems to be favorable. The additional value of many conservative therapies remains controversial. Because a systematic review of the conservative treatment of sciatica is lacking, such a review was carried out. After a standardized literature search and selection procedure, methodology and outcome of randomized controlled trials (RCTs) were assessed by three observers. If possible, trial results were statistically pooled (= metaanalysis). The 19 RCTs that were selected showed greatly varying methodologic quality. Pooled odds ratios were calculated for several treatment types. Neither traction, exercise therapy, nor drug therapy was unequivocally effective. Epidural steroids may be beneficial for subgroups of nerve root compression. The literature suggests possible effectiveness of epidural steroids for sciatica. The authors recommend trials to investigate this treatment option further, especially with regard to patient subgroups (e.g., acute sciatica). The effects of clinical heterogeneity and methodology on review results are illustrated.     

Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review

Objective  This systematic review aimed to evaluate the short- and long-term safety, efficacy and costs of stapled haemorrhoidopexy (SH) compared with conventional haemorrhoidectomy.
Method  We searched 26 electronic databases and websites for studies in any language up to July 2006. Inclusion criteria were predefined, and each stage of the review process was conducted in duplicate.
Results  Twenty-seven randomized controlled trials were included ( n  = 2279). All had some methodological flaws. Postoperatively, 19 trials (95%) reported less pain, 17 (89%) reported a shorter operating time, 14 (88%) a shorter hospital stay, and 14 (93%) a shorter convalescence time following SH. However, prolapse was significantly more common after SH (OR 3.38; 95% CI: 1.00, 11.47). In the longer term, prolapse was significantly more common after SH (OR 4.34; 95% CI: 1.67, 11.28) as was reintervention for prolapse (OR 6.78; 95% CI: 2.00, 23.00). There were no differences in the rate or type of complications. Conventional haemorrhoidectomy and SH had similar costs during the initial admission.
Conclusion  Compared with conventional haemorrhoidectomy, SH resulted in less postoperative pain, shorter operating time, a shorter hospital stay, and a shorter convalescence, but a higher rate of prolapse and reintervention for prolapse.