| Background and purposeIn recent years,the global prevalence of diabetes is increasing.The 2015 data shows that the global population of diabeties has reached to 415 million.Diabetic kidney disease is one of the major complications of diabetes,and the incidence rate is also increasing.Diabetic kidney disease with non-diabetic renal disease(NDRD)is also common to see.Single-center data from different countries and regions indicates that the incidence of NDRD in patients with DKD who have renal biopsy may account for 3%-82.9%.The data from our country shows that the proportion of patients with diabetic renal biopsy accounted for 2.57% at the end of the 20 th century.while in the 21 st century this figure has risen to 4.31%.At the same time,the incidence of nondiabetic renal disease(NDRD)was found to increase from 10.9% to 18.8%.In recent years,the detection rate of idiopathic membranous nephropathy(IMN)in NDRD is also increasing,and has become the most common pathological in NDRD.Currently,there are many studies on the clinicopathological features of IMN patients with DKD.With the development of renal biopsy,diagnosis for NDRD is not difficult,but its treatment is currently based on the principle of treatment of primary pathological types.The research on the effectiveness and safety of its treatment plan is rare.At present,the treatment of IMN is graded,and the KDIGO guidelines recommend the use of a corticosteroid combined with an alkylating agent(cyclophosphamide)or a calcineurin inhibitor(cyclosporine or tacrolimus)in patients with high-risk IMN.However,due to the large side effects of cyclophosphamide,and studies have shown that tacrolimus remission rate is better than cyclophosphamide in the sixth mounth,so the therapy of corticosteroids combined with tacrolimus treatment is chose to clinical use.However,both corticosteroids and tacrolimus have the risk of raising blood glucose,and the risk of infection can be further increased.Therefore,the use of immunosuppressive in patients of DM+IMN has been limited in the past.The Tripterygium wilfordii treatment that don't affect blood sugar and has a weak immunosuppressive effect is also widely used in clinical practice.However,the clinical efficacy,complications,and adverse drug effects of the two therapy are still blank at home and abroad.Therefore,in this study,the IMN high-risk group who were diagnosed by renal pathology at the same time were used as blank control,and the DM+IMN Patients in the high-risk group wree divided into two groups,one were treated with corticosteroids and immunosuppressive therapy,the other were threated with Tripterygium wilfordii.Both groups were observed retrospectively,and the clinical efficacy and safety of immunosuppressant treatment were analyzed.Datas and MethodsThis study collected ward and outpatient follow-up records of DM patients with IMN and IMN patients without DM retrospectively.All patients were diagnosed by renal biopsy at the First Affiliated Hospital of Zhengzhou University from June 2012 to June 2017.The renal tissue obtained from the renal biopsy of the First Affiliated Hospital of Zhengzhou University had all undergone immunofluorescence tests,and were examined by light microscopy and electron microscopy.With the control of blood glucose on the premise,the remission rate,cardiovascular and cerebrovascular complications,Cases of adverse drug reactions are compared in the follow-up period of 0 to 12 months.At the same time,the high-risk IMN patients without DM combined who were treated with immunosuppressive are blank control groups.The shortest follow-up time was observed as the longest observation contrast time which was one year.The treatment effects,complications,and adverse reactions in the three groups were followed up for 3 months,6 months,and 12 months.Statistical MethodsSPSS22.0 statistical software was used for statistical analysis.The data with normal distribution of continuous variables are expressed as the mean ± standard deviation(X ±s);the data with non-normal distribution are with median(25% quantile,75% quantiles)[ M(1/4,3/4)] indicates that the categorical variable use case(%).If the continuous variables meet the normal distribution and homogeneity of variances,the t test is used for comparison.Otherwise,the Wilcoxon rank sum test is used.The Pearson ?2 test,continuous correction,or Fisher's exact test is used for the comparison between the categorical variables.P<0.05 was considered statistically significant.Results1.General situation:Twenty-three cases of DM+IMN immunosuppressive group and 21 cases of DM+IMN Tripterygium wilfordii group were enrolled.Fifty cases of eligible IMN immunosuppressive group were randomly selected.The median duration of diabetes in DM+IMN immunosuppressive group and Triptolide group was less than 5 years.The two groups were combined with hypertension ratio,proteinuria level,serum albumin level,serum creatinine level,eGFR level,pathological stage of IMN,etc.No significant difference(all P>0.05).The fasting blood glucose and glycosylated hemoglobin levels in the DM+IMN immunosuppressive group were higher than those in the IMN immunosuppressive group(P<0.05),but the eGFR levels were lower in the IMN group than in the IMN group(P<0.001).There was no significant difference in proteinuria,serum albumin,serum creatinine,pathological stage of IMN,combined hypertension,and blood pressure between the two groups(all P>0.05).See Table 1.2.The effect of treatmenta.Comparison between DM+IMN immunosuppressive group and Tripterygium wilfordii group: There was no significant difference in remission rate between the two groups at 3 months follow-up,and the total remission rate in the immunosuppressant group was significantly higher than that of Tripterygium wilfordii group at 6 months(P=0.040)..Among the 18 patients with 6-month non-remission treatment in triptolide group,15 patients were treated with corticosteroid and tacrolimus.The cumulative survival rate and complete remission rate survival curve suggested that the treatment group was followed up by triptolide.There was no significant difference between the 1 year group and the immunosuppressive group(P>0.05)(see Figures 4 and 5).b.Comparison between DM+IMN immunosuppressive group and IMN immunosuppressive group: Comparison of cumulative survival rate and complete remission rate survival curve between the two groups suggested that the response rate of DM+IMN immunosuppressive group was lower than that of IMN immunosuppressive group(P<0.05).),Excluding unremitted patients,the median remission(PR)time was prolonged in the DM+IMN group compared to the IMN group [5(4,7)months vs2(1,4)months,P=0.001],complete remission(PR))Time was also prolonged [7(6.25,8.75)months vs5(3,7)months,P=0.047)].3.Complications and adverse reactionsPatients with DM+IMN had a higher risk of further increase in blood glucose after treatment with corticosteroids and immunosuppressive agents(P<0.001).Blood glucose worsening patients were promptly adjusted for compliance during follow-up,but complicated with pulmonary infections,cardiovascular and cerebrovascular complications,and There was no significant difference between ESRD risk and control group(P>0.05).See Table 3 for the comparison of the three groups.Conclusion Patients with DM+IMN in the treatment of corticosteroid combined with tacrolimus had a higher clinical remission rate than the group with Tripterygium wilfordii.Comparing with simple IMN,the remission time was prolonged while the remission rate,security and effective has no significant difference. |
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