诊断学理论与实践 ›› 2024, Vol. 23 ›› Issue (06): 587-593.doi: 10.16150/j.1671-2870.2024.06.005
张俊花1,2, 李一林3, 谢静远2, 张春丽2, 徐静2()
收稿日期:
2024-06-27
出版日期:
2024-12-25
发布日期:
2024-12-25
通讯作者:
徐静 E-mail:xjjesse@126.com基金资助:
ZHANG Junhua1,2, LI Yilin3, XIE Jingyuan2, ZHANG Chunli2, XU Jing2()
Received:
2024-06-27
Published:
2024-12-25
Online:
2024-12-25
摘要:
目的: 分析C3肾小球病(C3 glomerulopathy,C3G)的临床预后相关病理特征。方法: 收集2012年至2022年于上海交通大学医学院附属瑞金医院肾内科住院且经肾活检组织学诊断为C3G的所有病例,共7例,回顾性分析其临床、病理及随访资料,观察预后相关病理特征。结果: 7例C3G患者(男/女,3/4),中位起病年龄51岁,中位确诊年龄为54岁,中位随访时间为84个月(48~144个月),2例失随访,2例预后不良,3例预后良好。2例患者临床表现为肾病综合征,3例伴肾功能不全,6例伴有血尿,7例均表现为低补体血症伴高血压,且均无明显肾外表现。长期随访患者5例,随访至2年时,1例尿蛋白及肌酐完全缓解,3例尿蛋白及肾功能稳定,1例尿蛋白增加、肾功能下降;随访至6年时3例预后较好,1例在随访2年时预后差的基础上尿蛋白进一步增加,肾功能明显下降,1例新进展至大量尿蛋白。随访6年时,回顾肾脏病理,3例预后好的病例以弥漫毛细血管内皮细胞增生伴中性粒细胞浸润为主要表现,而肾小球球性硬化及毛细血管襻假双轨表现不明显,且系膜区电子致密物沉积较少;2例预后差的病例以肾小球球性硬化比例升高、大量毛细血管襻假双轨、系膜区大量电子致密物沉积为主要表现,而毛细血管内皮细胞增生伴中性粒细胞及嗜酸性粒细胞浸润较少。结论: C3G组织病理以急性病变(肾小球毛细血管内皮细胞增生、中性粒细胞浸润等)为主要表现者,预后较好,可予以激素、免疫抑制剂为主的积极治疗;C3G病理组织表现以慢性病变(肾小球球性硬化、毛细血管襻假双轨形成、系膜区电子致密物沉积量等)为主要表现,患者则预后不良,建议予以保守治疗,避免过度治疗。
中图分类号:
张俊花, 李一林, 谢静远, 张春丽, 徐静. C3肾病临床预后相关病理特征分析[J]. 诊断学理论与实践, 2024, 23(06): 587-593.
ZHANG Junhua, LI Yilin, XIE Jingyuan, ZHANG Chunli, XU Jing. Analysis of pathological features related to clinical prognosis in C3 glomerulopathy[J]. Journal of Diagnostics Concepts & Practice, 2024, 23(06): 587-593.
表1
患者临床资料
Index | case1 | case2 | case3 | case4 | case5 | case6 | case7 |
---|---|---|---|---|---|---|---|
Baseline data | |||||||
Gender | Female | Female | Female | Female | Male | Male | Male |
Age of onset(years) | 51 | 42 | 58 | 18 | 54 | 58 | 26 |
Age at diagnosis(years) | 51 | 54 | 64 | 23 | 57 | 58 | 29 |
Follow up(months) | 3 | 108 | 48 | 72 | 144 | 84 | 0 |
Family history | No | No | No | No | No | No | No |
SP(mmHg) | 137 | 118 | 128 | 120 | 124 | 180 | 138 |
DP(mmHg) | 81 | 90 | 89 | 74 | 86 | 96 | 85 |
NS | No | No | Yes | No | No | No | Yes |
24 h TUP(mg) | 2274 | 1632 | 4092 | 1508 | 877 | 1538 | 6301 |
Microscopic hematuria(/HP) | 11-15 | 6-11 | 4-5 | Full field | 6-10 | 4-5 | 0 |
Scr(μmol/L) | 175 | 55 | 102 | 47 | 94 | 113 | 78 |
eGFR(mL/min) | 28.6 | 114.5 | 49.2 | 134.1 | 79.8 | 61.4 | 116 |
sAlb(g/L) | 25 | 26 | 26 | 30 | 30 | 33 | 29 |
C3(g/L) | 0.28 | 0.06 | 0.6 | 0.6 | 0.56 | 0.62 | 0.43 |
C4(g/L) | 0.1 | 0.1 | 0.18 | 0.12 | 0.12 | 0.2 | 0.18 |
Hb(g/L) | 119 | 113 | 92 | 108 | 115 | 122 | 150 |
Therapy | MMF+P | ARB+P | ARB+P+CYC | ARB | ARB+P+MMF | ARB | ARB+P+CYC |
Remission time(months) | 3 | 3 | 2 | 3 | 32 | No | NA |
Relapse(months) | NA | 18 | No | 46 | 67 | No | NA |
Follow up for 2 years data | |||||||
Therapy | NA | ARB+P+CNI | ARB | ARB | ARB+P+MMF | ARB+P+MMF | NA |
24 h TUP(mg) | NA | 1542 | 155 | 954 | 352 | 2273 | NA |
Scr(μmol/L) | NA | 62 | 78 | 54 | 100 | 157 | NA |
eGFR(ml/min) | NA | 991 | 68.1 | 142.1 | 72.6 | 43.25 | NA |
sAlb(g/L) | NA | 29 | 42 | 33 | 35 | 27 | NA |
C3(g/L) | NA | 0.06 | NA | 0.08 | 0.64 | NA | NA |
C4(g/L) | NA | 0.1 | NA | 0.1 | 0.1 | NA | NA |
Follow up for 6 years data | |||||||
Therapy | NA | ARB+P+CNI | NA | ARB | ARB+P+RTX | ARB+P+MMF | NA |
24 h TUP(mg) | NA | 1236 | NA | 354 | 6013 | 3627 | NA |
Scr(μmol/L) | NA | 69 | NA | 51 | 131 | 202 | NA |
eGFR(mL/min) | NA | 96 | NA | 126.9 | 53.5 | 29.2 | NA |
sAlb(g/L) | NA | 29 | NA | 39 | 17 | 26 | NA |
C3(g/L) | NA | 0.07 | NA | 0.46 | 0.59 | NA | NA |
C4(g/L) | NA | 0.1 | NA | 0.2 | 0.2 | NA | NA |
表2
患者活检组织学特征
Index | case1 | case2* | case3* | case4* | case5 | case6 | case7 |
---|---|---|---|---|---|---|---|
LM | |||||||
Glomerulus(n) | 36 | 6 | 33 | 29 | 19 | 22 | 39 |
Glomerulosclerosis(n,%) | 2(5.6) | 0(0) | 3(9) | 0(0) | 3(15.8) | 5(26.3) | 12(30.8) |
Proportion of glomerulosclerosis increased | 0 | 0 | 0 | 0 | 0 | 1 | 1 |
Segmental sclerosis(n) | 2 | 0 | 0 | 2 | 0 | 0 | 5 |
Endocapillary proliferation | 1 | 1 | 1 | 1 | 0 | 0 | 0 |
Neutrophils in capillaries | 1 | 1 | 1 | 1 | 0 | 0 | 0 |
Capillary loop double track | 0 | 0 | 0 | 0 | 1 | 1 | 1 |
Mesangial matrix increased | 3 | 3 | 3 | 3 | 2 | 3 | 3 |
Mesangial cells increased | 1 | 3 | 3 | 3 | 2 | 3 | 2 |
Interstitial fibrosis | 1 | 1 | 1 | 1 | 1 | 2 | 2 |
Tubules atrophic | 1 | 1 | 1 | 1 | 1 | 2 | 2 |
Interstitial inflammatory cell | 1 | 1 | 3 | 1 | 1 | 2 | 2 |
IF | |||||||
Deposition of C3 | 2 | 3 | 3 | 3 | 2 | 2 | 2 |
other immune complexes | 0 | 1 | 0 | 1 | 0 | 1 | 0 |
EM | |||||||
Electron dense deposits | |||||||
Mesangial zone | 1 | 1 | 1 | 0 | 3 | 2 | 2 |
Epithelial side | 0 | 1 | 1 | 0 | 0 | 0 | 2 |
Subepithelial | 0 | 0 | 1 | 1 | 1 | 2 | 2 |
GBM | 0 | 0 | 1 | 0 | 0 | 0 | 2 |
Foot process fusion | 1 | 1 | 1 | 0 | 1 | 0 | 1 |
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