成人特发性膜性肾病临床病理特征及预后分析

史美萍; 金钟大

doi:10.3969/j.issn.1671-2390.2024.07.003

成人特发性膜性肾病临床病理特征及预后分析

Clinicopathological characteristics and outcomes of adult idiopathic membranous nephropathy

摘要

摘要:
目的探讨成人特发性膜性肾病（idiopathic membranous nephropathy，IMN）的临床病理特征及预后，分析IMN肾脏结局的影响因素。
方法收集2012年1月至2023年6月于广东省中医院肾病中心就诊，首次经肾活检确诊为IMN的646例患者的临床和病理资料进行回顾性分析，采用Cox比例风险模型和Kaplan-Meier生存曲线对截止至2023年12月随访时间≥6个月的486例患者进行生存分析。
结果（1）646例IMN患者中，男女比例为1.33∶1，≥40岁患者521例（80.7%），病理分期以Ⅱ期为主（472例，73.1%），肾小球球性硬化387例（59.9%），节段性硬化99例（15.3%），肾小管间质病变554例（85.8%），肾小血管病变540例（83.6%）。（2）单因素Cox回归结果显示，年龄、血肌酐、血尿酸、高血压、三酰甘油、24 h尿蛋白定量、球性硬化、节段性硬化、肾小管间质病变是肾脏预后不良的危险因素，而估算肾小球滤过率、血浆白蛋白、血红蛋白是肾脏结局的保护因素，多因素校正后只有年龄是肾脏预后不良的独立危险因素（HR = 1.042，95%CI：1.015～1.069，P = 0.002）。（3）Kaplan-Meier生存曲线分析结果显示，中度、重度球性硬化组患者肾脏生存率低于无球性硬化组和轻度球性硬化组（P＜0.05）；节段性硬化组患者肾脏生存率显著低于无节段性硬化组（P＜0.001）；中重度肾小管间质病变组患者肾脏生存率显著低于无间质病变组（P = 0.001）和轻度间质病变组（P = 0.001）。
结论 IMN好发于中老年人群，中度和重度肾小球球性硬化、节段性硬化以及中重度肾小管间质病变IMN患者肾脏生存率降低，但只有年龄能作为肾脏结局的独立预测因子。

Abstract:
Objective To explore the clinicopathological features and outcomes of adult idiopathic membranous nephropathy (IMN) and examine the influencing factors of renal outcomes.

Methods From January 2012 to June 2023, the clinicopathological data were retrospectively reviewed for 646 patients diagnosed initially as IMN by renal biopsy. Cox proportional risk model and Kaplan-Meier survival curve were utilized for conducting survival analysis for 486 patients with a follow-up duration of at least 6 months until December 2023.
Results Among 646 IMN patients, male-to-female ratio was 1.33∶1 and 521 patients (80.7%) were aged ≥40 year. The predominant pathological stage was II (73.1%). There were glomerular global sclerosis (n=387, 59.9%), segmental sclerosis (n=99, 15.3%), renal tubulointerstitial lesions (n=554, 85.8%) and renal small vessel lesions (n=540, 83.6%). Single-factor Cox regression analysis revealed that advanced age, serum creatinine, uric acid, hypertension, triglyceride, 24 h urine protein quantification, glomerular global sclerosis, segmental sclerosis and tubulointerstitial lesions were the risk factors for poor renal outcomes whereas eGFR, plasma albumin and hemoglobin were the protective factors. After multifactorial corrections, only age was an independent risk factor for poor renal outcomes (HR=1.042, 95%CI: 1.015-1.069, P=0.002). Kaplan-Meier survival curve analysis revealed that renal survival rates were lower in moderate/severe glomerular global sclerosis group than those in non-glomerular global sclerosis and mild glomerular global sclerosis groups (P<0.05). Renal survival rate was significantly lower in segmental sclerosis group than non-sclerosis groups (P<0.001). Group with moderate-to-severe tubulointerstitial lesions had significantly lower renal survival rates than group without tubulointerstitial lesions (P=0.001) and group with mild tubulointerstitial lesions (P=0.001).
Conclusions IMN is prevalent in middle-aged and elderly people. Moderate/severe glomerular global sclerosis, segmental sclerosis and moderate-to-severe tubulointerstitial lesions collectively contribute to a lower renal survival rate in IMN patients. However, only age may be employed as an independent predictor of renal outcomes.

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