Nasr Samih H, Markowitz Glen S, Stokes Michael B, Said Samar M, Valeri Anthony M, D'Agati Vivette D
From Department of Pathology (SHN, GSM, MBS, SMS, VDD) and Department of Medicine, Division of Nephrology (AMV), Columbia University, College of Physicians & Surgeons, New York, New York.
Medicine (Baltimore). 2008 Jan;87(1):21-32. doi: 10.1097/md.0b013e318161b0fc.
Acute postinfectious glomerulonephritis (APIGN) is uncommon in adults, and its incidence is progressively declining in developed countries. To our knowledge there are no modern North American series addressing epidemiology and outcome. Here we report the clinical and pathologic findings in 86 cases of adult APIGN diagnosed by renal biopsy in a large New York referral center between 1995 and 2005. The male:female ratio was 2:1, and mean age was 56 years, with 33.7% aged older than 64 years. Of the patients, 38.4% had an immunocompromised background, including diabetes (29.1%), malignancy (4.7%), alcoholism (2.3%), acquired immunodeficiency syndrome (AIDS) (2.3%), and intravenous drug use (1.2%). The most common sites of infection were upper respiratory tract (23.3%), skin (17.4%), lung (17.4%), and heart/endocarditis (11.6%). The 2 most frequently identified infectious agents were streptococcus (27.9%) and staphylococcus (24.4%). Hypocomplementemia was present in 73.9% of patients. The most common histologic patterns were diffuse (72.1%), focal (12.8%), and mesangial (8.1%) proliferative glomerulonephritis. Outcome analysis was performed on the 52 patients with a follow-up of >/=3 months (mean, 25 mo). Among the 41 patients without underlying diabetic glomerulosclerosis, 23 (56.1%) achieved complete remission, 11 (26.8%) had persistent renal dysfunction, and 7 (17.1%) progressed to end-stage renal disease (ESRD). Of the 11 patients with underlying diabetic glomerulosclerosis, 2 (18.2%) had persistent renal dysfunction, and the remaining 9 (81.8%) progressed to ESRD (p < 0.001). In patients without underlying diabetic glomerulosclerosis, correlates of complete remission were younger age, female sex, lower serum creatinine at biopsy, and absence of immunocompromised state. By multivariate analysis, age and serum creatinine at biopsy inversely correlated with complete remission, and serum creatinine at biopsy was the only correlate with ESRD. Outcome did not correlate with any pathologic feature (including crescents) or steroid treatment. Diabetes and aging have emerged as major risk factors for adult APIGN. Full recovery of renal function can be expected in just over half of patients, and prognosis is dismal in those with underlying diabetic glomerulosclerosis.
急性感染后肾小球肾炎（APIGN）在成人中并不常见，在发达国家其发病率正在逐渐下降。据我们所知，目前尚无关于北美地区该病流行病学及预后情况的现代研究系列报道。在此，我们报告了1995年至2005年间在纽约一家大型转诊中心通过肾活检确诊的86例成人APIGN患者的临床及病理表现。男女比例为2:1，平均年龄为56岁，其中33.7%的患者年龄超过64岁。在这些患者中，38.4%有免疫功能低下背景，包括糖尿病（29.1%）、恶性肿瘤（4.7%）、酗酒（2.3%）、获得性免疫缺陷综合征（艾滋病，2.3%）以及静脉吸毒（1.2%）。最常见的感染部位是上呼吸道（23.3%）、皮肤（17.4%）、肺部（17.4%）以及心脏/心内膜炎（11.6%）。最常检测到的两种感染病原体是链球菌（27.9%）和葡萄球菌（24.4%）。73.9%的患者存在低补体血症。最常见的组织学类型为弥漫性（72.1%）、局灶性（12.8%）和系膜增生性肾小球肾炎（8.1%）。对52例随访时间≥3个月（平均25个月）的患者进行了预后分析。在41例无潜在糖尿病性肾小球硬化的患者中，23例（56.1%）实现完全缓解，11例（26.8%）持续存在肾功能不全，7例（17.1%）进展至终末期肾病（ESRD）。在11例有潜在糖尿病性肾小球硬化的患者中，2例（18.2%）持续存在肾功能不全，其余9例（81.8%）进展至终末期肾病（p<0.001）。在无潜在糖尿病性肾小球硬化的患者中，完全缓解的相关因素包括年龄较轻、女性、活检时血清肌酐水平较低以及无免疫功能低下状态。多因素分析显示，年龄和活检时血清肌酐水平与完全缓解呈负相关，活检时血清肌酐水平是与ESRD唯一相关的因素。预后与任何病理特征（包括新月体）或类固醇治疗均无关联。糖尿病和老龄化已成为成人APIGN的主要危险因素。略超过半数的患者肾功能有望完全恢复，而有潜在糖尿病性肾小球硬化的患者预后不佳。
