Рецепт. 2019; : 559-568
Эффективность глюкокортикостероидов в лечении IgA-нефропатии
Аннотация
Цель исследования: оценить основные показания, частоту назначения и эффективность глюкокортикостероидов (ГК) у пациентов с IgA-нефропатией (ИГАН) по результатам работы нефрологических отделений Минска.
Материалы и методы. Ретроспективно были изучены истории пациентов с гистологически верифицированным диагнозом ИГАН, которые наблюдались в 2015–2017 гг. Критериями исключения из анализа были возраст пациента младше 18лет, наличие менее 8 клубочков в почечном биоптате, вторичные формы гломерулонефрита. Состояние почечной функции оценивали по рассчитанной скорости клубочковой фильтрации (СКФ). Морфологический диагноз оценивался согласно Оксфордской классификации МЕST-C.
Результаты. За анализируемый период времени диагноз ИГАН был выставлен 91 пациенту, что составило 22,8% от общего числа выполненных нефробиопсий. Из них 18 (26,9%) пациентам были назначены ГК. Средний возраст пациентов был 35,4±12,6 года, из них 66,7% мужчин. Артериальная гипертензия (АГ) была диагностирована у 10 (55,6%) пациентов. Основными показаниями для назначения ГК были: изолированный мочевой синдром – 10 (55,5%), нефритический синдром, который наблюдался у 6 (33,5 %) человек, нефротический синдром и острое почечное повреждение, наблюдаемые с одинаковой частотой – 5,5%. Гистологически у большинства пациентов отмечалась мезангиальная пролиферация (М1). Все пациенты получали метилированные аналоги преднизолона, которые назначались согласно трем режимам на период, не превышающий 8 месяцев. При этом 11 (61%) человек, которым были назначены ГК, достигли клинико-лабораторной ремиссии, а у 3 (17%) наблюдалась регрессия болезни. Лечение было неэффективным у 4 пациентов, при этом у 3 был нефритический синдром, а у 1 – изолированный мочевой синдром, у всех было отмечено снижение СКФ ниже 60 мл/минуту, протеинурия более 1 г/сутки. Характерной чертой гистологической картины, согласно МЕST-C, было преобладание склеротических изменений над пролиферативными, у 2 пациентов тубулярная атрофия превышала 50%, и у всех был сегментарный склероз, тогда как мезангиальная пролиферация была у 2, а эндотелиальная у одного человека.
Заключение. По данным нашего исследования, ГК назначались четверти пациентам с ИГАН и они были эффективны у пациентов с изолированным мочевым синдромом, сохранной почечной функцией и имеющих М1, S1 и Т0 в соответствии с MEST-C. Тяжелых побочных эффектов лечения не зафиксировано.
Список литературы
1. Woo K.T., G.S. Lee G.S., Lau Y.K. (1991) Effects of triaple therapy in IgA nephritis: a follow-up study 5 years later. Clin Nephrol, vol. 36, no 2, pp. 60–66.
2. Lv J., Zhang H., Chen Y. (2009) Combination therapy of prednisolone and ACE inhibitor versus ACE inhibitor therapy alone in patients with IgA nephropathy: a randomized controlled trial. Am J Kidney Dis, vol. 53, no 1, pp. 26–32.
3. Pozzi, C., Andrulli S., Del VL. (2004) Corticosteroid effectiveness in IgA nephropathy: long-term results of a randomized controlled trial. J Am Soc Nephrol, vol. 15, no 1, pp. 157–163.
4. Chen, K-J., Cheng Ch-H, Wu M-I. (2003) Effect of corticosteroid and cyclophosphamide in IgA nephropathy patients with heavy proteinuria and/or moderate-severe pathological changes. J Chin Med Assoc, vol. 66, no 5, pp. 263–270.
5. Trimarchi H., Barratt J., Cattran D.C. (2017) Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group. Kidney International, vol. 91, no5, pp. 1014–1021.
6. Cortinovis M., Ruggenenti P., Remuzzi G. (2016) Progression, Remission and regression of chronic renal disease. Nephron, vol. 134, no 1, pp. 20–24.
7. Coppo R., Troyanov S., Bellur S. (2014) VALIGA study of the ERA-EDTA Immunonephrology Working Group: Validation of the Oxford classification of IgA nephropathy in cohorts with different presentations and treatments. Kidney Int, vol. 86, no 4, pp. 828–836.
8. Yoshikawa N., Ito H., Sakai T. (1999) A controlled trial of combined therapy for newly diagnosed severe childhood IgA nephropathy. The Japanese Pediatric IgA Nephropathy Treatment Study Group. J Am Soc Nephrol, vol. 10, no 1, pp. 101–109.
9. Barbour S.J., Espino-Hernandez G., Reich H.N. (2016) Oxford Derivation, North American Validation and VALIGA Consortia: The MEST score provides earlier risk prediction in IgA nephropathy. Kidney Int, vol. 89, no 1, pp. 167–175.
10. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group: KDIGO Clinical Practice Guideline for Glomerulonephritis. Immunoglobulin A nephropathy. (2012) Kidney Int Suppl, vol. 2, no 2, pp. 139–274.
11. Chakera A., MacEwen C., Bellur S.S. (2016) Prognostic value of endocapillary hypercellularity in IgA nephropathy patients with no immunosuppression. J Nephrol, vol. 29, no 3, pp. 367–375.
12. Beckwith H., Medjeral-Thomas N., Galliford J. (2017) Mycophenolate mofetil therapy in immunoglobulin A nephropathy: histological changes after treatment. Nephrol Dial Transplant., vol. 32, suppl. 1, pp. 123–128.
13. Rauen T., Eitner F., Fitzner C. (2015) STOP-IgAN Investigators: Intensive supportive care plus immunosuppression in IgA nephropathy. N Engl J Med, vol. 373, no 23, pp. 2225–2236.
14. Bellur S.S., Lepeytre F., Vorobyeva O. (2017) International IgA Nephropathy Working Group: Evidence from the Oxford Classification cohort supports the clinical value of subclassification of focal segmental glomerulosclerosis in IgA nephropathy. Kidney Int, vol. 91, no 1, pp. 235–243.
15. Trimarchi H., Barratt J., Cattran D.C. (2017) IgAN Classification Working Group of the International IgA Nephropathy Network and the Renal Pathology Society; Conference Participants: Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group. Kidney Int, vol. 91, no 5, pp. 1014–1021.
16. Haas M., Verhave J.C., Liu Z.H. (2017) A multicenter study of the predictive value of crescents in IgA nephropathy. J Am Soc Nephrol, vol. 28, no 2, pp. 691–701.
Recipe. 2019; : 559-568
Efficiency of Glucocorticosteroids IgA-nephropathy Treatment
Abstract
The aim of the study was to estimate the main indication, frequency of prescribing and efficiency of glucocorticosteroids (GC) in patients with IgA-nephropathy (IgAN) according to results of work of nephrological units in Minsk.
Materials and Methods. Retrospectively there were studied histories of patients with histology verification of IgAN diagnosis, who were following up in 2015–2017 years. The excluding criteria were age less than 18 years, less than 8 glomerulus in kidney biopsy, secondary forms of this glomerulonephritis. Renal function was assessed by estimated glomerular filtration rate (GFR). Pathological diagnosis was estimated according to Oxford classification (MEST-C).
Results. For analyzing period of time diagnosis of IgAN was put 91 patients that it was 22.8% from total number of performed nephrobiopsies. From them 18 (26.9%) patients were prescribed GK. Mean age of the patients was 35.4±12.6 years from them 66.7% male. Arterial hypertension was diagnosed in 10 (55.6%). The main indications for starting GC were isolated urine syndrome 10 (55.5%), then followed nephritic which was 6 (33.5%) people whereas nephrotic and acute kidney injury were in equal percent of cases 5.5%. Most patients had mesangial proliferation (M1) according to pathological evaluation. All of the patients took methylated analogues of prednisolone which were prescribed according to 3 regimes for period was up to 8 months. Wherein 11 (61%) people on GC achieved clinical laboratory remission, but in 3 (17%) had regression of the disease. The treatment was ineffective in 4 (22%) patients, 3 had nephritic syndrome but 1 – isolated urine syndrome. Initially all failed patients had GFR less 60 ml/min and proteinuria was more than 1 g/d. The main characteristic of histopathological picture according to MEST-C was domination of sclerotic changes over proliferative, in 2patients there was tubular atrophy more than 50% and all had segmental sclerosis while there were mesangial proliferation in 2 and endothelial in 1 people.
Conclusions. According to our study GC was prescribed to one fourth of patients with IgAN and it was effective in isolated urine syndrome, preserved renal function and there were M1, S1 and T0 according to MEST-C. There were no severe adverse effects during course of GC treatment.
References
1. Woo K.T., G.S. Lee G.S., Lau Y.K. (1991) Effects of triaple therapy in IgA nephritis: a follow-up study 5 years later. Clin Nephrol, vol. 36, no 2, pp. 60–66.
2. Lv J., Zhang H., Chen Y. (2009) Combination therapy of prednisolone and ACE inhibitor versus ACE inhibitor therapy alone in patients with IgA nephropathy: a randomized controlled trial. Am J Kidney Dis, vol. 53, no 1, pp. 26–32.
3. Pozzi, C., Andrulli S., Del VL. (2004) Corticosteroid effectiveness in IgA nephropathy: long-term results of a randomized controlled trial. J Am Soc Nephrol, vol. 15, no 1, pp. 157–163.
4. Chen, K-J., Cheng Ch-H, Wu M-I. (2003) Effect of corticosteroid and cyclophosphamide in IgA nephropathy patients with heavy proteinuria and/or moderate-severe pathological changes. J Chin Med Assoc, vol. 66, no 5, pp. 263–270.
5. Trimarchi H., Barratt J., Cattran D.C. (2017) Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group. Kidney International, vol. 91, no5, pp. 1014–1021.
6. Cortinovis M., Ruggenenti P., Remuzzi G. (2016) Progression, Remission and regression of chronic renal disease. Nephron, vol. 134, no 1, pp. 20–24.
7. Coppo R., Troyanov S., Bellur S. (2014) VALIGA study of the ERA-EDTA Immunonephrology Working Group: Validation of the Oxford classification of IgA nephropathy in cohorts with different presentations and treatments. Kidney Int, vol. 86, no 4, pp. 828–836.
8. Yoshikawa N., Ito H., Sakai T. (1999) A controlled trial of combined therapy for newly diagnosed severe childhood IgA nephropathy. The Japanese Pediatric IgA Nephropathy Treatment Study Group. J Am Soc Nephrol, vol. 10, no 1, pp. 101–109.
9. Barbour S.J., Espino-Hernandez G., Reich H.N. (2016) Oxford Derivation, North American Validation and VALIGA Consortia: The MEST score provides earlier risk prediction in IgA nephropathy. Kidney Int, vol. 89, no 1, pp. 167–175.
10. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group: KDIGO Clinical Practice Guideline for Glomerulonephritis. Immunoglobulin A nephropathy. (2012) Kidney Int Suppl, vol. 2, no 2, pp. 139–274.
11. Chakera A., MacEwen C., Bellur S.S. (2016) Prognostic value of endocapillary hypercellularity in IgA nephropathy patients with no immunosuppression. J Nephrol, vol. 29, no 3, pp. 367–375.
12. Beckwith H., Medjeral-Thomas N., Galliford J. (2017) Mycophenolate mofetil therapy in immunoglobulin A nephropathy: histological changes after treatment. Nephrol Dial Transplant., vol. 32, suppl. 1, pp. 123–128.
13. Rauen T., Eitner F., Fitzner C. (2015) STOP-IgAN Investigators: Intensive supportive care plus immunosuppression in IgA nephropathy. N Engl J Med, vol. 373, no 23, pp. 2225–2236.
14. Bellur S.S., Lepeytre F., Vorobyeva O. (2017) International IgA Nephropathy Working Group: Evidence from the Oxford Classification cohort supports the clinical value of subclassification of focal segmental glomerulosclerosis in IgA nephropathy. Kidney Int, vol. 91, no 1, pp. 235–243.
15. Trimarchi H., Barratt J., Cattran D.C. (2017) IgAN Classification Working Group of the International IgA Nephropathy Network and the Renal Pathology Society; Conference Participants: Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group. Kidney Int, vol. 91, no 5, pp. 1014–1021.
16. Haas M., Verhave J.C., Liu Z.H. (2017) A multicenter study of the predictive value of crescents in IgA nephropathy. J Am Soc Nephrol, vol. 28, no 2, pp. 691–701.
