微量蛋白尿合并肾功能不全的IgA肾病患者临床病理特点及预后分析

目的　分析微量蛋白尿合并肾功能不全的IgA肾病患者的临床、病理特点及预后。方法　选取经皮肾脏穿刺活检术诊断为原发性IgA肾病且24 h尿蛋白定量≤0.5 g的患者162例。根据血肌酐值将其分为肾功能正常组（n=107，血肌酐≤115 μmol/L）和肾功能不全组（n=55，血肌酐＞115 μmol/L）。收集患者肾穿刺活检当次住院的临床病理资料，分析2组临床、病理特点及预后，Kaplan-Meier法绘制生存曲线，比较2组肾脏生存率的差异；采用Cox比例风险模型分析微量蛋白尿的IgA肾病患者进入终点事件的危险因素。结果　与肾功能正常组患者比较，肾功能不全组患者男性、合并高血压患者比例、年龄、白蛋白、血肌酐、血尿酸、三酰甘油、中性粒细胞和血钾水平均较高，血红蛋白水平、血小板计数较低（P＜0.05）；肾功能不全组患者伴有节段性硬化或黏连（S1）的肾小球较多,肾小管萎缩或（和）肾间质纤维化（T1/T2）占比及新月体（C1/C2）占比较高，缺血硬化肾小球、节段硬化肾小球、细胞/细胞纤维性新月体占比较高，小动脉损伤较重（P＜0.05）。生存分析结果显示，肾功能不全组患者较肾功能正常组肾脏累积生存率低（Log-rank χ2=24.960，P＜0.01）。多因素Cox比例风险模型分析显示，血肌酐升高、血红蛋白降低和小动脉损伤是微量蛋白尿合并肾功能不全患者进入终点事件的独立危险因素（P＜0.05）。结论　微量蛋白尿合并肾功能不全较单纯微量蛋白尿IgA肾病患者临床及病理改变更重，预后更差。

Clinicopathological characteristics and prognostic analysis of IgA nephropathy patients with microalbuminuria and renal insufficiency

Objective　To analyze the clinical data, pathological characteristics and prognosis of IgA nephropathy patients with microalbuminuria and renal insufficiency. Methods　A total of 162 patients with primary IgA nephropathy diagnosed by percutaneous renal biopsy and 24 hour urinary protein quantification (≤0.5 g) were selected. They were divided into the normal renal function group (n=107, the serum creatinine ≤115 μmol/L) and the renal insufficiency group (n=55, the serum creatinine > 115 μmol/L) according to their creatinine values. The clinicopathological data of patients hospitalized with renal puncture biopsy were collected, and the clinical and pathological characteristics and prognosis were analyzed between the two groups. The survival curve was plotted by Kaplan-Meier method to compare the difference in renal survival rate between the two groups. Cox proportional risk model was used to analyze the risk factors of end-point events in IgA nephropathy patients with microalbuminuria. Results　Compared with the normal renal function group, the proportion of male patients and proportion of patients with hypertension, age, albumin, serum creatinine, serum uric acid, triglyceride, neutrophils and potassium levels were higher in the renal insufficiency group, and the levels of hemoglobin and platelets were lower (P＜0.05). Patients in the renal insufficiency group showed more segmental sclerosis synechia (S1) of the glomerulus, higher proportion of renal tubular atrophy or (and) renal interstitial fibrosis (T1/T2) and crescents (C1/C2), and higher proportion of glomerular ischemia sclerosis, glomerular segmental sclerosis, cell/fibrous crescents, and heavier arteriole injury (P＜0.05). The results of survival analysis showed that the cumulative renal survival rate was lower in patients with renal insufficiency than that of patients with normal renal function (Log-rank χ2=24.960，P＜0.01). Multivariate Cox proportional risk model analysis showed that the increased serum creatinine, decreased hemoglobin and small arterial injury were independent risk factors for end-point events in patients with microproteinuria combined with renal insufficiency (P＜0.05). Conclusion　The clinical and pathological changes of microproteinuria combined with renal insufficiency are more severe and the prognosis is worse than those of IgA nephropathy with microproteinuria alone.