Milovanova S Iu, Tégaĭ S V, Russkikh A V, Kozlovskaia L V
Ter Arkh. 2011;83(11):38-43.
To reveal clinical and morphological characteristics of renal damage in patients with cryoglobulinemia (CGE) associated with chronic viral hepatitis C (CVH-C) for upgrading diagnosis, prognosis and optimization of the treatment methods.
Two groups of CVH-C patients were studied: with CGE (group 1, n = 64) and free of CGE (group 2, n = 62) matched for gender, age and duration of the disease. Biopsy of the liver for assessment of the histological activity index and histological sclerosis index by METAVIR scale was conducted in 63 patients. Of patients with CGE-related damage to the kidneys, 48 were examined for clinical picture with morphological investigation of renal tissue in 15 of them including semiquantitative evaluation of fibrosis degree and activity.
Patients with CVH-C and CGE had a wider spectrum of systemic lesions than CVH-C patients without CGE. Only CGE patients demonstrated more severe affection of the skin, joints, kidneys and the nervous system. Therefore, CGE can be considered as a marker of poor prognosis. Liver biopsy showed that CGE patients had more pronounced fibrosis (3-6 points) versus 0-2 points in 80% patients from group 2. Duration of CVH-C from probable infection to renal damage in 48 patients with CGE glomerulonephritis (GN) averaged 197.05 +/- 18.5 months. Renal biopsy diagnosed CGE mesangiocapillary GN in 13 patients and membranoproliferative GN in 2 patients. Patients with HCV infection had a more severe proliferative form of nephritis--mesangiocapillary GN. In 48 GN patients with HCV-infection and CGE, GN ran latently with moderate urinary syndrome in 29 (60.4%) patients, with nephrotic syndrome--in 9 (18.6%), with acute nephritic syndrome--in 10 (21.0%) patients. Most of the patients had arterial hypertension, 13 patients had creatinemia (3.02 +/- 0.55 mg/dl), rapidly progressive GN was diagnosed in 4 patients.
Persistent CGE marks poor prognosis in CHC patients and is an indication for antiviral treatment to prevent severe organ lesions, first of all of the kidneys. Development of CGE vasculitis with severe damage to the kidneys demands immunosuppressive therapy in combination with plasmapheresis or cryapheresis followed by antiviral drugs. As shown by pilot results, a new approach with rituximab is perspective but further evidence is needed for final conclusions.
揭示与慢性丙型病毒性肝炎（CVH-C）相关的冷球蛋白血症（CGE）患者肾脏损害的临床和形态学特征，以提升诊断、预后评估及优化治疗方法。
研究两组CVH-C患者：患有CGE的患者（第1组，n = 64）和未患CGE的患者（第2组，n = 62），两组在性别、年龄和病程方面相匹配。对63例患者进行肝脏活检，采用METAVIR量表评估组织学活性指数和组织学硬化指数。在患有CGE相关肾脏损害的患者中，48例接受了临床检查，其中15例进行了肾组织形态学检查，包括纤维化程度和活性的半定量评估。
与无CGE的CVH-C患者相比，患有CVH-C和CGE的患者全身病变谱更广。仅CGE患者的皮肤、关节、肾脏和神经系统受累更为严重。因此，CGE可被视为预后不良的标志物。肝脏活检显示，CGE患者的纤维化更为明显（3 - 6分），而第2组80%的患者为0 - 2分。48例患有CGE肾小球肾炎（GN）的患者，从可能感染到肾脏损害的CVH-C病程平均为197.05±18.5个月。肾活检诊断13例患者为CGE系膜毛细血管性GN，2例为膜增生性GN。丙型肝炎病毒感染患者的肾炎增殖形式更为严重——系膜毛细血管性GN。在48例患有丙型肝炎病毒感染和CGE的GN患者中，29例（60.4%）患者的GN呈潜伏性，伴有中度尿综合征，9例（18.6%）患者伴有肾病综合征，10例（21.0%）患者伴有急性肾炎综合征。大多数患者患有动脉高血压，13例患者有肌酐血症（3.02±0.55mg/dl），4例患者被诊断为快速进行性GN。
持续性CGE标志着慢性丙型肝炎患者预后不良，是进行抗病毒治疗以预防严重器官损害（首先是肾脏损害）的指征。伴有严重肾脏损害的CGE血管炎的发生需要免疫抑制治疗联合血浆置换或冷沉淀去除术，随后使用抗病毒药物。初步结果表明，利妥昔单抗的新方法具有前景，但需要更多证据才能得出最终结论。
