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題名 | Clinical Characteristics and Outcomes of Immunoglobulin A Nephropathy Patients with Heavy Proteinuria: Therapeutic Roles of Steroids and Renin-Angiotensin System Inhibitiors=甲型免疫球蛋白腎病變併重度蛋白尿患者的臨床特色和預後:類固醇和腎素-血管張力素系統抑制劑的治療角色 |
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作者姓名(中文) | 劉信良; 許杏如; 謝日耀; 黃建鐘; | 書刊名 | 臺灣腎臟醫學會雜誌 |
卷期 | 16:2 2002.06[民91.06] |
頁次 | 頁66-72+96 |
分類號 | 415.74 |
關鍵詞 | 甲型免疫球蛋白腎病變; 蛋白尿; 類固醇; 血管張力素轉換酶抑制劑; 第二血管張力素受器拮抗劑; IgA nephropathy; Proteinuria; Angiotensin-converting enzyme inhibitors; ACEIs; Angiotensin receptor blockers; ARBs; Corticosteroids; Renal insufficiency; |
語文 | 英文(English) |
中文摘要 | 甲型免疫球蛋白腎病變(IgA nephropathy, IgAN)是全世界最常見的腎絲球腎炎(glomerulonephritis),以二十至三十歲的成人居多,男女比例為二至三比一,病因迄今仍無定論。臨床的表現為無痛性之肉眼或顯微血尿、蛋白尿以及腎功能的逐漸衰退。約有20%的病患在二十年後進入末期腎病(end-stage renal disease);而預後的不良指標,包括:發病初期即有腎功能不良或高血壓者,重度或達腎病症候群蛋白尿(heavy or nephrotic-ranged proteinuria)者,病理切片呈現腎小管間質性病變(tubulointerstitial nephropathy)或腎絲球有半月體(crescent)生成者。關於IgAN的治療,證據顯示類固醇(steroids)可減輕蛋白尿的嚴重度和維持腎功能穩定;對高血壓的病患,血管張力素轉化酶抑制劑(angiotensin-converting enzyme inhibitors, ACEIs)為首要之選擇,但血壓正常的患者,也可減輕蛋白尿;第二血管張力素第一型受器阻斷劑(angiotensin II type l receptor blockers, ARBs),也有類似的效果。另有報告指出類固醇合併cyclophosphamide治療,可以減緩IgAN病程之進展。因重度蛋白尿(每天尿蛋白流失量大於三公克)是影響IgAN預後的一個重要因子,而且類固醇和ACEIs/ARBs治療皆能有效地降低蛋白尿;我們在成大醫院進行一回溯性研究,探討具重度蛋白尿的IgAN患者對類固醇及/或ACEIs/ARBs的治療反應。根據腎臟病理切片報告,共收集了102位IgAN病患,採病歷回溯方式,研究期間是由確立病理診斷起,追蹤至2002年12月31日(平均45個月),排除26位失去追蹤、七位過敏性紫斑(HSP)和九位年齡小於16歲的病患;我們一共分析60位IgAN患者的臨床表現、藥物使用和生化檢驗數據。在確立病理診斷時,有33位為輕、中度蛋白尿和27位為重度蛋白尿患者;後者之病理組織變化較為嚴重(第三和四級),且平均的舒張壓較高。在這些27位重度蛋白尿中,排除5位順服性不佳的病患後,有八位使用類固醇、八位使用ACEIs/ARBs和六位接受合併療法。分析此三種不同治療方式對蛋白尿的改善程度,發現單獨使用類固醇患者,降低38±63%(P<0.05);ACEIs/ARBs患者可降低35±56%(P>0.05)的尿蛋白排出量;而合併治療者,可降低65±19%(P<0.01)。三組治療反應的相互比較,沒有統計學之差異,且容易復發;但合併治療組,沒有不反應者。本研究的最大限制為病患人數較少且無法排除不良預後因子對結果之影響,所以合併類固醇和ACEI/ARBs治療,對重度蛋白尿患者是否可達到較好的成效,仍需要更多患者之前瞻性研究來加以驗證。 |
英文摘要 | IgA nephropathy (IgAN) is the most common primary glomerulonephritis (GN) worldwide. Although most IgAN patients have a benign course, the natural history of those with heavy proteinuria is quite variable. Several studies show that corticosteroids (steroids) therapy can decrease proteinuria and stabilize the renal function. Also, angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers (ARBs) have the benefit of decreasing proteinuria for IgAN patients with and without hypertension. Because heavy proteinuria is an important poor prognostic factor of IgAN, it is worthy to compare the therapeutic responses of corticosteroids, ACEIs/ARBs, and combined therapy of both agents in these patients with heavy proteinuria (i.e. daily protein loss≧3 g). Therefore, a retrospective study of 102 biopsy-proved IgAN patients was conducted in our hospital. We analyzed the clinical features, laboratory data, and managements by reviewing medical records, and 42 patients were excluded, including loss of follow-up in 26 cases, Henoch-Schonlein purpura in 7, and children in 9. In total, 60 patients with normal renal function were enrolled in this study. Thirty-three of them presented with mild-moderate proteinuria and 27 cases with heavy proteinuria. The heavy proteinuria group shared the similar clinical features with the mild-moderate proteinuria group, but these patients had a more advanced histological changes (i.e. grades III and IV) and higher mean diastolic blood pressure. Among these 27 patients, 8 were treated with steroids, 8 with ACEIs/ARBs, and 6 with combined therapy (i.e. steroids plus ACEIs/ARBs). And the other five patients were excluded due to poor compliance, including one in steroids group, one in ACEIs/ARBs group, and three in combined therapy group. After a follow-up of 40.3±31.9 months, we found that daily protein loss decreased 38% in steroids alone group (P<0.05), 35% in ACEIs/ARBs therapy group (P>0.05), and 65% in combined therapy group (P<0.01). Although there were no significant differences of proteinuria reduction among the three subgroups of IgAN patients with heavy proteinuria, there was no non-responder in combined therapy group. Prospective clinical trials are mandatory to prove the efficacy of steroids plus ACEI or ARB therapy in IgA patients with heavy proteinuria. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。