IgA肾病继发恶性高血压和急性肾损伤的临床和病理分析

目的 分析IgA肾病继发恶性高血压(MHT)和急性肾损伤(AKI)的临床、病理特点和预后.方法 对12例IgA肾病继发MHT和AKI患者(MHT IgA肾病组)和15例无MHT且肾功能正常的IgA肾病患者(非MHT IgA肾病组)的临床、病理资料进行回顾性分析,并随访其预后.结果 MHT IgA肾病组6例表现为急进性肾炎综合征,其中4例合并肾病综合征,3例表现肉眼血尿；其他6例表现为镜下血尿、蛋白尿(尿蛋白定量≥1.5 g/d)及AKI；随访期内12例MHT IgA肾病组患者均表现为进行性肾功能损害.非MHTIgA肾病组3例表现肾病综合征,3例表现肉眼血尿,8例为慢性肾小球肾炎,1例为隐匿性肾小球疾病；随访期内肾功能无明显进展.MHT IgA肾病组从发病至肾活检的时间明显短于非MHT IgA肾病组短(22±16)d比(85 ±62)d,P＜0.01],血清肌酐、尿酸、IgA、C反应蛋白及尿蛋白水平均明显高于对照组(242±92) μmol/L比(85±14) μmol/L,P＜0.01;( 486±121) μmol/L比(358±100) μmol/L,P＜0.01;(4.8±1.3)g/L比(3.6±1.3) g/L,P＜0.05；(13±8) mg/L比(6±4) mg/L,P＜0.01；(3.2±1.3)g/d比(2.2±1.2)g/d,P＜0.05].肾活检病理示MHT IgA肾病组肾小球、间质、血管病变明显较非MHT IgA肾病组重,MHT IgA肾病组Lee's分级≥Ⅲ级者所占比例明显高于非MHT IgA肾病组100.0％ (12/12)比46.7％(7/15),P＜0.01].结论 IgA肾病继发MHT和AKI者临床病情重,肾脏病理病变重、预后差.影响肾功能转归的因素可能包括MHT持续时间、肾活检时血肌酐值、肾脏病理的严重程度和降压治疗是否达标.

Clinical and pathologic characteristics of IgA nephropathy with malignant hypertension and acute kidney injury

Objective To analyze the clinical pathological characteristics and prognosis of IgA nephropathy with malignant hypertension（MHT） and acute kidney injure（AKI）. Methods The clinical and histological data of 12 eases with IgA nephropathy, accompanied with MHT and AKI（ MHT IgA nephropathy group） , and 15 IgA ne- phropathy cases without MHT and AKI （non-MHT IgA nephropathy gourp） were analyzed retrospectively. Results Of the 12 patients of MHT IgA nephropathy group, 6 cases had progressive glomerulonephritis syndrome, 4 cases were nephrotic syndrome and 3 cases represented gross hematuria. The other 6 patients manifested microscope hematuria, proteinuria（24 h proteinuria higher than or equal to 1.5 g/d） and AKI. All the patients in MHT IgA ne-phropathy group showed accelerated kidney function loss during follow-up. In non-MHT IgA nephropathy gourp, 8 cases were chronic glomerulonephritis, 3 cases were nephritic syndrome, 1 case was latent glomerulonephritis and 3 cases showed gross hematuria. Kidney function did not show deteriorated tendency during follow-up. Duration of renal biopsy development in MHT IgA nephropathy patients were much longer than that in non-MHT IgA nephropathy group （22 ±16）d vs （85±62 ）d, P 〈 0. 01 ]. Compared with non-MHT IgA nephropathy, serum creatinine, uric acid, IgA, C-reactive protein and urine protein levels in MHT IgA nephropathy group were significantly incrased （ 242±92 ） μmol/L vs （ 85 ±14 ）μmol/L, P 〈 0.01 ; （486 ± 121） μmol/L vs （ 358±100 ）μmol/L, P 〈 0. 01 ; （ 4. 8 ±1.3）g/Lvs（3.6＋1.3）g/L, P〈0.05;（13±8）mg/L vs（6±4）mg/L,P〈0.01;（3.2 ＋1.3）g/d vs（2.2± 1.2） g/d,P 〈0. 051. Pathological changes of glomeruli, renal interstitium and interstitum vascular were found in MHT IgA nephropathy. According to Lee classification ,the pathological classifications more than grades Ill account for 100.0% （12/12）in MHT IgA nephropathy, while 46. 7% （7/15） in non-MHT IgA nephropathy group（ P 〈 0. 01 ）. Conclusions Renal lesion in IgA nephropathy with MHT and AKI is serious and the prognosis is worse. The prognosis may depend on duration, serum creatinine level at the time of biopsy, the degree of pathological dam- age and whether antihypertensive treatment reaches standards.