呈慢性肾炎的IgA肾病96例临床病理和预后分析

目的：探讨在原发性IgA肾病（IgAN）中如何早期作出慢性肾小球肾炎（慢性肾炎）的临床诊断。方法：于1993年3月-2009年8月我院肾活检资料库中选取成人原发性IgAN 96例,所有病例血肌酐（Scr）在正常高值（苦味酸法≥105μmol/L或酶法≥77μmol/L）持续3月以上;按内生肌酐清除率（Ccr）分2组：A组Ccr≥60 mL/min 43例,B组Ccr〈60mL/min 53例;行临床病理及预后比较分析。随访终点为Scr翻倍或Ccr〈15 mL/min。结果：96例IgAN,病程中出现尿蛋白〉1.0 g/d 70例（73.0%）,肾活检时平均Ccr（59.15±20.73）mL/min,重度肾小球硬化79例（占82.3%）,中重度小管间质病变73例（占76.0%）。随访中位数18.5个月,21例进入终点。B组中重度肾小管间质病变和肾病范围蛋白尿的发生率均显著高于A组,分别为84.9%vs 65.1%和41.5%vs 18.6%,差异有统计学意义（均P〈0.05）。B组和A组的平均随访中位数分别为33个月和21个月（0.25～102个月）,终点事件的发生率分别为28.0%和14.0%。结论：在IgAN中,慢性肾炎的基本临床病理特征是：①持续性尿蛋白〉1.0 g/d;②持续性Ccr下降;③肾活检病理存在伴重度肾小球硬化的中重度小管间质病变。该3项可作为慢性肾炎临床诊断的早期指标。

Analysis of clinico-pathological characteristics and prognosis in 96 patients of IgA nephropathy with chronic glomerulonephritis

Objective: To discuss the early diagnostic criterion of chronic glomerulo-nephritis in primary IgA Nephropathy(IgAN).Methods: From march 1993 to august 2009,96 biopsy-proven IgAN patients from The First Affiliated Hospital of Wenzhou Medical College with serum creatinine level above the upper limit(Scr≥105μmol/L by picric kinetic method) were enrolled in this study.The patients were divided into two groups according to creatinine clearance rate(Ccr): Group A(Ccr≥60 mL/min,n =43),and group B(Ccr<60 mL/min,n =53).Two groups of patients with clinico-pathological characteristics and prognosis were compared and analyzed.Endpoint was defined as double of baseline serum creatinine or Ccr<15 mL/min.Results: Among 96 cases with IgAN,incidence of proteinuria>1.0 g/day,severe glomerular sclerosis,moderate to severe tubelointerstitial lesions was 73.0%,82.3% and 76.0% respectively,and the average Ccr at renal biopsy was(59.15±20.73) mL/min.All cases with a median follow-up of 18.5 months,21 patients developed to ESRD.The incidence of intermediate to severe tubulointerstitial lesions and nephrotic-range proteinuria in group B was significantly higher than that in group A(84.9% vs 65.1%,P <0.05 and 41.5% vs 18.6%,P <0.05,respectively).Patients in B and A groups were followed-up for a median duration of 33 and 21 months,respectively,28.0% and 14.0% patients reaching the endpoint.Conclusion: For patients with IgAN,the fundamental clinico-pathological features of chronic glomerulonephritis are as follows:①durative proteinuria>1.0 g/day;②lasting Ccr decrease;③moderate to severe tubulointerstitial lesions accompanied with severe glomerular sclerosis.The three items men-tioned above may be used as the early diagnostic criterion for chronic glomerulonephritis.