The Analysis Of Clinical, Pathological And Prognostic Relationship Of IgA Nephropathy Presented By Nephrotic Proteinuria

Objective:To analysis the clinicopathological features and relationship of IgA nephropathy presented by nephrotic proteinuria,to investigate the influence of clinical parameters,renal pathological lesions and treatment on renal survival.Methods:The clinical and pathological data of eighty patients with IgA nephropathy presented by nephrotic proteinuria were analyzed retrospectively.Histological evaluation of patholiogical lesions was based on the histological grading and semiquantitative integral for IgAN described by Lee and Kathafuchi,acute and chronic changes were estimated separately,which was the method used by Shigemastsu.We used Kruskal-Wallis H test to investigate the relationships of the clinical and pathological features.Kaplan-Meier curves and Cox proportional hazards model were also used in the renal survival analysis.Comparisons between different treatment groups were by the chi-square method.Results:1(1) General indices:Among 80 patients,46 male and 34 female,mean age(35.58±13.3)years old.20-40 year-old age group was the most prominent.(2) Clinical characteristics:25%patients had an incentive before onste.Mean course of disease was 21.55 months.Incidence of gross hematuria,hypertension,renal decrescence was 22.5%,32.5%and 53.75%,respectively.There was no significant difference in incidence of gross hematuria between the normal renal function group and decreased renal function group.62.5 percent of the patients were with edema at onset.The level of plasma albumin was significantly higher in edema group than that in non- edema group.(3) Pathological lesions:GradeⅣwas the most prominent in those patients,holding 37.5%.Immunofluorescence:the common deposition of IgA, IgM and C3 was the most prominent in glomerular mesangial region,holding 33.75%. (4) There was no relationship between crescent with the other pathological lesions. But there was positive correlation between glomerulosclerosis with inflammatory infiltration,interstitial fibrosis,tubular atrophy and vessel lesions,in contrast. 2 The relationship between clinical and histopathological changes:(1)There was no significant difference of the distribution of pathological grade and the scores of pathological lesions in different hematuria group(P＞0.05).The scores of lesions of global glomerulosclerosis,inflammatory infiltration,interstitial fibrosis,tubular atrophy and vessel lesions in the decreased renal fuction group were higher than that in the normal renal function group,which had statistically significance(P＜0.05). Pathological grade was rising with the increase of the hypertensive grade.The scores of lesions of global glomerulosclerosis,interstitial fibrosis,tubular atrophy and vessel lesions in hypertensive group were significantly higher than that in normal hypertension group.(2) There was positive correlation between urinary protein and crescent lesions.The positive correlation of global glomerulosclerosis,inflammatory infiltration,interstitial fibrosis,tubular atrophy and vessel lesions was mean arterial pressure,the negative correlation were eGFR and hemoglobin.(3) The proteinuria with no glomerulosclerosis was higher than that with glomerulosclerosis,significantly (P=0.007).But there was no significant difference in groups of different degree of glomerulosclerosis.The higher the sclerosis scores were,the higher MAP was,the lower eGFR was,the more severe renal anemia,acute and chronic tubulointerstitial lesions and vessel lesions were.(4) The patients in GradeⅤnot only had severe chronic lesions,but also had serious acute lesions including crescents and inflammatory infiltration.(5) The degree of sclerosis(P=0.041) and inflammatory infiltration(P=0.031) was higher when there was stronger intensity of IgA in immufluorescence,as well as the pathological grade(P=0.046).3 Renal survival analysis and estimate of the prognostic factors:54 patients were followed up,follow-up period was 2-60 months.12 patients developed to renal deterioration,6 patients required dialysis or renal transplantation,2 patients died of uremia.Since renal biopsy,the survival rates were 94%at 6 months,94%at 1year,90% at 2 years,80%at 3 years,63%at 5 years.Univariate Cox regression indicated the following parameters as risk factors:proteinuria,mean arterial pressure,eGFR, hemoglobin,global glomerulosclerosis,inflammatory infiltration,interstitial fibrosis, tubular atrophy and vessel lesions.Multivariate Cox regression indicated the following parameters as the independent risk factors:proteinuria,mean arterial pressure,renal anemia and vessel lesions(OR=1.799,1.052,0.860,21.163). Kaplan-Meier curve indicated the following parameters as risk factors:mean arterial pressure≥106.7mmHg,eGFR＜60ml/min,hemoglobin＜110g/L,scores of global glomerulosclerosis＞6,severe inflammatory infiltration(scores＞2),severe interstitial fibrosis(scores＞2),moderate and severe tubular atrophy(scores＞1),vascular intima thickening and glass samples.4 Treatment:one patient didn't receive the regular treatment,2 patients were treated with ACRI or ARB alone,no remission.34 patients were treated with oral steroids,17 patients were treated with prednisone and immunosuppressive agents.22 patients achieve the remission in group of prednisone,with the rate of 64.7%,14 patients achieve the remission in group of therapeutic alliance,with the rate of 82.4%,there was no significant difference between two groups in remission rate.The complete remission rate in group of prednisone and therapeutic alliance were 14.7%vs 17.6%, which was with no statistically significance.Conclusion:1 The common age range in IgA nephropathy with nephrotic proteinuria was from 20 to 40 year-old.The clinicopathological characteristics were not slight.The renal survival at 1year and 5years were lower than the average level of IgA nephropathy.2 Hematuria,whether gross hematuria or not,whatever degree of microhematuria was, was not the impact factor of pathological lesions in IgA nepropathy presented by neprhotic syndrome.The urinary protein excretion increased with crescent lesions., which could reflect the acute gloermular lesions.The high MAP,the low eGFR and the moderate or severe renal anemia were the important parameters that reflected the severity of chronic lesions.3 Proteinuria,mean arterial pressure,renal anemia and vessel were the independent risk factors of renal survival.4 Mean arterial pressure≥106.7mmHg,eGFR＜60ml/min,hemoglobin＜110g/L, scores of global glomerulosclerosis＞6,severe inflammatory infiltration(scores＞2), severe interstitial fibrosis(scores＞2),moderate and severe tubular atrophy(scores＞1), vascular intima thickening and glass samples were risk factors of renal survival.5 We founded that the steroid therapy or immunosuppressive agents could decrease proteinuria effectively and protected renal function.But the difference of these two therapeutic effect remains large sample RCT researches to prove.