狼疮肾炎肾功能不全可逆因素的探讨
【摘 要】 目的 探讨狼疮肾炎(LN)肾功能不全病人与肾功能可逆性相关的因素。方法 采用回顾性队列研究策略，对1991—1999年住院的173例LN肾功能不全患者进行6个月的随访。结局因素：氮质血症者血肌酐下降至116 μmol/L以下，尿毒症者血肌酐下降50%以上，并脱离透析3个月以上为阳性结局，死亡者因其肾功能不可能再恢复，因此删失时间为28周。研究因素包括性别、年龄、病程、症状、并发症、狼疮活动指数、各种常规、生化和免疫学检查、药物治疗等51个变量。统计学方法：采用COX比例危险率回归模型分析。结果 142例(82.1%)完成随访。93例(65.0%)肾功能恢复(阳性结局)，17例(12.0%)死亡。在运用COX回归的多因素分析，去除混杂因素影响后，仍然显示对LN肾功能不全的肾功能恢复有影响的因素包括：环磷酰胺(CTX)治疗，性别，肾功能不全的病程，肾脏大小，贫血和血肌酐值。其中CTX治疗可促进肾功能恢复，每周剂量≤0.25 g/m2时肾功能恢复的危险比(HR)为4.41，95%的可信区间(CI)为(1.03，18.94)，每周剂量＞0.25 g/m2时的HR为13.29，95%CI为(3.11，56.82)。男性HR为0.51，95%CI为(0.27，0.95)；肾功能不全的病程(月)的HR为0.68，95%CI为(0.53，0.87)；肾脏缩小的HR为0.08，95%CI为(0.01，0.62)；血红蛋白80～100 g/L的HR为0.43，95%CI为(0.23，0.79)；血红蛋白60～80 g/L的HR为0.34，95%CI为(0.19，0.63)；血红蛋白＜60 g/L的HR为0.31，95%CI为(0.14，0.67)；血肌酐值(每增高100 μmol/L)的HR为0.84，95%CI为(0.74，0.96)。结论 男性、肾功能不全的病程延长、肾脏缩小、贫血和血肌酐值较高，均不利于LN肾功能不全患者肾功能的恢复；而CTX治疗可以促进其肾功能的恢复。
【关键词】 狼疮肾炎； 肾功能衰竭； 预后； 比例危险度模型
On the reversible factors of renal failure in lupus nephritis
YANG Xiuyan LIANG Liuqin YE Yujin
（Department of Rheumatology and Clinical Immunology,Affiliated First Hospital Sun Yat-sen University of Medical Sciences,Guangzhou 510080,China）
【Abstract】 Objective To explore the potential clinical predictors associated with the recovery of renal function in new onset azotemia and uremia in patients with lupus nephritis (LN).Methods Factors influencing recovery of renal function in LN patients were examined in a six-month retrospective cohort study.Records of a sample of 173 consecutive in-patients of recently diagnosed renal failure with LN from 1991 to 1998 were examined.The outcome factor was recovery of renal function (serum creatinine ≤116 μmol/L) in azotemia patients or a 50% reduction of serum creatinine and discontinuation of dialysis in uremic patients,improved for at least three months.The study factors included demographic,clinical,laboratory and therapeutic data.These study factors and outcome variable were analysed with two structured abstracting forms.Results Complete records to assess follow-up were available for 142 (82.1%) subjects from the cohort.After 6 months of follow-up,93 patients (65.5%) recovered their renal function and 17 (12.0%) died.Afteeon,the following study factors were found to be significantly associated with recovery of renal function:gender,renal dysfunction duration,renal size,anaemia,creatinine and intravenous cyclophosphamide therapy.The hazard ratio(HR)for male was 0.51 and 95%CI (0.27,0.95).The monthly HR for duration of renal failure was 0.68 and 95%CI (0.53,0.87).The HR of anaemia with Hb 80～100 g/L was 0.43 and 95%CI (0.23,0.79).The HR of anaemia with Hb 60～80 g/L was 0.34 and 95%CI (0.19,0.63).The HR of anaemia with Hb＜60 g/L was 0.31 and 95%CI (0.14,0.67).The HR for the increase of 100 μmol/L serum creatinine was 0.84 and 95%CI (0.74,0.96).Conclusion Male,longer duration of renal failure,small renal size,anaemia and higher serum creatinine level are all poor predictors of recovery of renal function in LN.Intravenous cyclophosphamide therapy with higher dose could have a pro-tective effect on the recovery of renal function in these patients.
【Key words】 Lupus nephritis; Renal failure; Prognosis; Proportional hazards models
终末期肾病是狼疮肾炎(LN)主要的死亡原因，LN肾功能不全的治疗决策仍是临床上的难题。环磷酰胺(CTX)冲击治疗可使部分病人的肾功能不全恢复，并文持正常生理功能［1］。但LN肾功能不全病人往往病情较重，体质较差，CTX冲击治疗可能使另一部分病人雪上加霜。因此，预测LN肾功能不全的预后，对指导临床治疗决策有重要意义。本研究旨在探讨LN肾功能不全的可逆因素，为临床决策提供参考。