Hsieh Yao P, Wen Yao K, Chen Moi L
Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.
Clin Nephrol. 2012 Jan;77(1):18-24. doi: 10.5414/cn107094.
The goal of this study is to determine the value of early renal biopsy as a therapeutic guide in systemic lupus erythematosus (SLE) patients presenting with renal involvement.
We retrospectively analyzed renal biopsies findings in SLE patients between January 2000 and December 2009 encountered at a medical center in Taiwan. An additional criterion for inclusion in this study was kidney biopsy done within 3 months of the first detection of sign(s) of renal disease.
There were 131 patients enrolled in this study. In patients presenting with acute renal failure, 91% of patients had proliferative lupus nephritis (Class IV, mixed Class V+III) and 9% had non-proliferative lupus nephropathy (pure Class V). In patients presenting with nephrotic range proteinuria, proliferative lupus nephritis (Class III, IV, mixed Class V+III) and non-proliferative lupus nephropathy (Class II, pure Class V) accounted for 55% and 36% of patients, respectively; and 9% had non-lupus nephropathy. In this group, except that elevated anti-double-stranded DNA antibody levels were more common in proliferative lupus nephritis (p = 0.043), no clinical findings could predict the renal morphology. In patients presenting with subnephrotic proteinuria, 49% of patients had proliferative lupus nephritis (Class III, IV, mixed Class V+III) and 51% had non-proliferative lupus nephropathy (Class II, pure Class V), and decreased C4 levels were more common in patients with proliferative lupus nephritis (p = 0.031). In patients presenting with isolated hematuria, all were not active forms of nephropathy. Immunosuppressive therapy was intensified because of biopsy findings in 29% of patients presenting with acute renal failure, 43% with nephrotic range proteinuria, and 53% with sub-nephrotic proteinuria.
Our data suggested that similar clinical renal manifestations may be observed despite very different classes of lupus nephritis. Clinicians tended to wait for histological identification of severe lupus nephritis before initiating potential harmful treatment with aggressive immunosuppressive therapy. Therefore, in SLE patients with clinical sign(s) of renal disease, early renal biopsy may be helpful in planning treatment.
本研究的目的是确定早期肾活检作为系统性红斑狼疮（SLE）合并肾脏受累患者治疗指导的价值。
我们回顾性分析了2000年1月至2009年12月间台湾某医疗中心收治的SLE患者的肾活检结果。本研究的另一个纳入标准是在首次发现肾脏疾病迹象后的3个月内进行肾活检。
本研究共纳入131例患者。在出现急性肾衰竭的患者中，91%的患者患有增殖性狼疮肾炎（IV级，V+III级混合），9%患有非增殖性狼疮肾病（纯V级）。在出现肾病范围蛋白尿的患者中，增殖性狼疮肾炎（III级、IV级、V+III级混合）和非增殖性狼疮肾病（II级、纯V级）分别占患者的55%和36%；9%患有非狼疮性肾病。在该组中，除了增殖性狼疮肾炎中抗双链DNA抗体水平升高更为常见外（p = 0.043），没有临床发现能够预测肾脏形态。在出现亚肾病范围蛋白尿的患者中，49%的患者患有增殖性狼疮肾炎（III级、IV级、V+III级混合），51%患有非增殖性狼疮肾病（II级、纯V级），增殖性狼疮肾炎患者中C4水平降低更为常见（p = 0.031）。在出现孤立性血尿的患者中，均不是肾病活动形式。29%出现急性肾衰竭的患者、43%出现肾病范围蛋白尿的患者以及53%出现亚肾病范围蛋白尿的患者因活检结果而加强了免疫抑制治疗。
我们的数据表明尽管狼疮肾炎的类别差异很大，但可能观察到相似的临床肾脏表现。临床医生往往会等待组织学鉴定出严重狼疮肾炎后才开始使用激进的免疫抑制疗法进行潜在的有害治疗。因此，对于有肾脏疾病临床迹象的SLE患者，早期肾活检可能有助于制定治疗方案。
