诊断学理论与实践 ›› 2022, Vol. 21 ›› Issue (04): 437-443.doi: 10.16150/j.1671-2870.2022.04.004
收稿日期:
2022-09-19
出版日期:
2022-08-25
发布日期:
2022-11-07
通讯作者:
张晖
E-mail:zhang.hui@zs-hospital.sh.cn
基金资助:
SHI Xia4, MA Xin, WANG Zhenyan, ZHANG Hui2(), LIU Shaojun3
Received:
2022-09-19
Online:
2022-08-25
Published:
2022-11-07
Contact:
ZHANG Hui
E-mail:zhang.hui@zs-hospital.sh.cn
摘要:
目的:分析人类免疫缺陷病毒(human immunodeficiency virus,HIV)感染合并慢性肾病患者的病理类型、临床特征及转归,以指导临床治疗。方法:收集上海市公共卫生临床中心2016年6月至2021年4月收治的HIV感染合并肾病并行超声引导下肾穿刺活检的病例32例,分析慢性肾病病理类型、临床情况以及转归。结果:32例患者中,男28例,女4例,平均年龄为(43.5±12.3)岁,CD4+T淋巴细胞计数为(425.9±240.4)个/μL,肾刺穿活检前26例(81.3%)已采用抗逆转录病毒治疗,治疗中位时间为24(1,72)个月。病理类型中,膜性肾病(8例,25.0%)和IgA肾病(6例,18.8%)占比居前;其次为糖尿病性肾病(5例,15.6%),未见经典HIV相关性肾病。随访3个月~5年,肾病缓解率达84.4%(完全缓解13例,部分缓解14例),未缓解率为9.4%(3例,包括1例狼疮样免疫复合物介导的增生性肾小球肾炎,1例糖尿病肾病,1例高血压肾病),病死率6.3%(2例,均为微小病变)。结论:HIV感染合并肾病患者的病理类型多样,主要病理类型为膜性肾病、IgA肾病、糖尿病性肾病,而经典HIV相关性肾病并不常见。根据肾活检病理结果,在抗逆转录病毒治疗基础上给予肾病相关治疗,能够较好地缓解肾病或延缓肾病进展,但微小病变型肾病患者可能预后欠佳。
中图分类号:
施霞, 马鑫, 王珍燕, 张晖, 刘少军. 32例人类免疫缺陷病毒感染合并慢性肾病患者的临床病理特征及随访结果分析[J]. 诊断学理论与实践, 2022, 21(04): 437-443.
SHI Xia, MA Xin, WANG Zhenyan, ZHANG Hui, LIU Shaojun. Analysis on the clinicopathological characteristics and follow-up of 32 patients with human immunodeficiency virus infection and chronic kidney diseases[J]. Journal of Diagnostics Concepts & Practice, 2022, 21(04): 437-443.
图4
糖尿病性肾病( Class Ⅲ)(男性,47岁) A:PAS染色(×400),肾小球部分节段可见系膜区显著扩张,部分节段呈典型的K-W结节样改变(箭头示),细动脉可见明显透明样变并致管腔稍狭窄;B:电镜(×8 000,80 kV),系膜区明显增宽,系膜基质大量增多伴系膜细胞轻度增生,部分呈结节状,少部分插入内皮下形成局部双轨,基底膜明显增厚,肾小球基底膜厚度为762~875 nm,足突明显脱落,TBM增厚;C:免疫荧光,IgG明显线样粘附于GBM和TBM,IgM极少量沉积在少数节段毛细血管壁,IgA(-),IgG(-),C1q(-),C3(-),Kappa(-),Lambda(-)。
表1
病理类型及转归[例(n)]
HIV感染合并肾病 | 病理分型 | 完全缓解 | 部分缓解 | 未缓解 | 死亡 | 总计 | 占比(%) |
---|---|---|---|---|---|---|---|
原发性肾小球疾病(免疫复合物介导) | 膜性肾病 | 5 | 3 | 8 | 25.0 | ||
IgA肾病 | 2 | 4 | 6 | 18.8 | |||
增生性肾小球肾炎伴单克隆免疫球蛋白沉积 | 1 | 1 | 3.1 | ||||
狼疮样免疫复合物介导的增生性肾小球肾炎 | 1 | 1 | 3.1 | ||||
系膜增生性肾小球肾炎 | 1 | 1 | 3.1 | ||||
膜增生性肾小球肾炎 | 1 | 1 | 3.1 | ||||
原发性肾小球疾病(足细胞病) | 微小病变 | 1 | 2 | 3 | 9.4 | ||
局灶节段性肾小球硬化症 | 1 | 1 | 3.1 | ||||
HIV相关性肾病 | 0 | 0.0 | |||||
继发性肾小球疾病 | 糖尿病肾病 | 1 | 3 | 1 | 5 | 15.6 | |
高血压性肾病 | 1 | 1 | 3.1 | ||||
紫癜性肾炎 | 1 | 1 | 3.1 | ||||
间质性肾炎 | 亚急性间质性肾炎 | 1 | 1 | 3.1 | |||
慢性活动性小管间质性肾炎 | 1 | 1 | 3.1 | ||||
肾穿刺组织不足 | 轻微病变 | 1 | 1 | 3.1 | |||
总计 | 13 | 14 | 3 | 2 | 32 |
[1] |
Cao Y, Gong M, Han Y, et al. Prevalence and risk factors for chronic kidney disease among HIV-infected antiretroviral therapy-naïve patients in mainland China: a multicenter cross-sectional study[J]. Nephrology (Carlton), 2013, 18(4):307-312.
doi: 10.1111/nep.12031 URL |
[2] |
Cheung CY, Wong KM, Lee MP, et al. Prevalence of chronic kidney disease in Chinese HIV-infected patients[J]. Nephrol Dial Transplant, 2007, 22(11):3186-3190.
doi: 10.1093/ndt/gfm350 URL |
[3] | 欣怡, 胡章学. 人类免疫缺陷病毒感染伴肾病患者的临床病理分析[J]. 中华实验和临床感染病杂志(电子版), 2020, 14(1):78-82. |
Xin Y, Hu ZX. Clinicopathological analysis of patients with human immunodeficiency virus infection andnephropathy[J]. Chin J Exp Clin Infect Dis(Electron Ed), 2020, 14(1):78-82. | |
[4] |
Swanepoel CR, Atta MG, D′Agati VD, et al. Kidney di-sease in the setting of HIV infection: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference[J]. Kidney Int, 2018, 93(3):545-559.
doi: S0085-2538(17)30823-2 pmid: 29398134 |
[5] |
上海市肾内科临床质量控制中心专家组. 慢性肾脏病早期筛查、诊断及防治指南(2022年版)[J]. 中华肾脏病杂志, 2022, 38(5):453-464.
doi: 10.3760/cma.j.cn441217-20210819-00067 |
Expert Group of Shanghai Renal Medicine Clinical Quality Control Center. Guidelines for early screening, diagnosis, prevention and treatment of chronic kidney disease (2022 Edition)[J]. Chin J Nephrol, 2022, 38(5):453-464.
doi: 10.3760/cma.j.cn441217-20210819-00067 |
|
[6] | 胡章学, 欣怡. 《HIV感染背景下的肾脏疾病:KDIGO争议会议的结论》解读[J]. 临床肾脏病杂志, 2019, 19(8):551-558. |
Hu ZX, Xin Y. Interpretation of "Kidney Disease in the Setting of HIV Infection: Conclusions from a KDIGO Controversies Conference"[J]. J Clin Nephrol, 2019, 19(8):551-558. | |
[7] | Naicker S, Rahmanian S, Kopp JB. HIV and chronic kidney disease[J]. ClinNephrol, 2015, 83(< W>7 Suppl 1):32-38. |
[8] |
Alfano G, Cappelli G, Fontana F, et al. Kidney Disease in HIV Infection[J]. J Clin Med, 2019, 8(8):1254.
doi: 10.3390/jcm8081254 URL |
[9] |
Jotwani V, Atta MG, Estrella MM. Kidney disease in HIV: moving beyond HIV-associated nephropathy[J]. J Am Soc Nephrol, 2017, 28(11):3142-3154.
doi: 10.1681/ASN.2017040468 pmid: 28784698 |
[10] |
Prakash J, Ganiger V, Prakash S, et al. Kidney disease in human immunodeficiency virus-seropositive patients: absence of human immunodeficiency virus-associated nephropathy was a characteristic feature[J]. Indian J Nephrol, 2017, 27(4):271-276.
doi: 10.4103/0971-4065.202400 pmid: 28761228 |
[11] | 陈惠萍, 曾彩虹, 胡伟新, 等. 10594例肾活检病理资料分析[J]. 肾脏病与透析肾移植杂志, 2000, 9(6):501-509. |
Chen HP, Zeng CH, Hu WX, et al. Analysis of 10594 renal biopsy data[J]. Chin J Nephrol, Dial & Transplant, 2000, 9(6):501-509. | |
[12] | 吴广礼. 中国慢性肾脏病疾病谱的变迁及防治策略[J]. 中华医学信息导报, 2020, 35(24):20. |
Wu GL. Changes in the spectrum of chronic kidney disea-se in China and its prevention and treatment strategies[J]. China Med News, 2020, 35(24):20. | |
[13] | 乐晓琴, 宋炜, 沈银忠, 等. 人类免疫缺陷病毒感染合并肾脏疾病患者的肾脏病理和临床特征[J]. 中华传染病杂志, 2020, 38(4):221-224. |
Le XQ, Song W, Shen YZ, et al. Renal pathology and clinical features of patients with human immunodeficiency virus infection complicated with kidney diseases[J]. Chin J Infect Dis, 2020, 38(4):221-224. | |
[14] |
Medapalli RK, He JC, Klotman PE. HIV-associated nephropathy: pathogenesis[J]. Curr Opin Nephrol Hypertens, 2011, 20(3):306-311.
doi: 10.1097/MNH.0b013e328345359a URL |
[15] |
Kopp JB, Heymann J, Winkler CA. APOL1 renal risk variants: fertile soil for HIV-associated nephropathy[J]. Semin Nephrol, 2017, 37(6):514-519.
doi: S0270-9295(17)30070-0 pmid: 29110758 |
[16] |
Lucas GM, Eustace JA, Sozio S, et al. Highly active antiretroviral therapy and the incidence of HIV-1-associated nephropathy: a 12-year cohort study[J]. AIDS, 2004, 18(3):541-546.
pmid: 15090808 |
[17] | Ekrikpo UE, Kengne AP, Bello AK, et al. Chronic kidney disease in the global adult HIV-infected population: a systematic review and meta-analysis[J]. PLoS One, 2018, 13(4):e0195443. |
[18] |
Fogo AB, Lusco MA, Najafian B, et al. AJKD atlas of renal pathology: HIV-associated immune complex kidney disease (HIVICK)[J]. Am J Kidney Dis, 2016, 68(2):e9-e10.
doi: 10.1053/j.ajkd.2016.06.003 URL |
[19] | Ma J, Zheng Q, Zhang H, et al. The spectrum of kidney biopsy findings in Chinese HIV-infected patients[J]. HIV Med, 2022, 23(Suppl 1):23-31. |
[20] |
Gameiro J, Jorge S, Lopes JA. HIV and renal disease: a contemporary review[J]. Int J STD AIDS, 2018, 29(7):714-719.
doi: 10.1177/0956462417750710 pmid: 29343165 |
[21] | 刘美玲, 张炯, 王金泉. 微小病变肾病合并急性肾损伤的研究进展[J]. 临床肾脏病杂志, 2021, 21(10):855-859. |
Liu ML, Zhang J, Wang JQ. Research advances of minimal change disease combined with acute kidney injury[J]. J Clin Nephrol, 2021, 21(10):855-859. | |
[22] |
Meyrier A, Niaudet P. Acute kidney injury complicating nephrotic syndrome of minimal change disease[J]. Kidney Int, 2018, 94(5):861-869.
doi: S0085-2538(18)30352-1 pmid: 29980292 |
[23] |
Gerntholtz TE, Goetsch SJ, Katz I. HIV-related nephropathy: a South African perspective[J]. Kidney Int, 2006, 69(10):1885-1891.
doi: 10.1038/sj.ki.5000351 pmid: 16625149 |
[24] |
Lucas GM, Ross MJ, Stock PG, et al. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America[J]. Clin Infect Dis, 2014, 59(9):e96-e138.
doi: 10.1093/cid/ciu617 URL |
[25] |
Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the management of chronic kidney disease in HIV-infec-ted patients: recommendations of the HIV Medicine Asso-ciation of the Infectious Diseases Society of America[J]. Clin Infect Dis, 2005, 40(11):1559-1585.
doi: 10.1086/430257 URL |
[26] | Elewa U, Sandri AM, Rizza SA, et al. Treatment of HIV-associated nephropathies[J]. Nephron Clin Pract, 2011, 118(4):e346-e354. |
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