Department of Medicine, Kidney Center, Tokyo Women's Medical University, Kawada-cho 8-1, Shinjuku-ku, Tokyo, 162-8666, Japan.
Clin Exp Nephrol. 2014 Apr;18(2):320-8. doi: 10.1007/s10157-013-0822-8. Epub 2013 Jun 7.
In recent years, tonsillectomy and steroid pulse (TSP) therapy have been widely performed in Japan. However, there is no consensus about the treatment protocol and indication.
In this retrospective analysis, we compared patients who received tonsillectomy plus intermittent steroid pulse (SP) therapy three times in 6 months (ISP group, n = 44) with patients who received tonsillectomy plus 3 weeks of consecutive SP therapy (CSP group, n = 46) within 1 year after renal biopsy. These two different protocols were performed at two different institutions. We analyzed the clinical and histological background and clinical remission (CR), defined as disappearance of urine abnormalities at 18 months after starting treatment.
Before treatment, there was no significant difference in the clinical findings except for sex between the two groups. In ISP group and CSP group, mean estimated glomerular filtration rate was 82.1 ± 20.9 and 85.9 ± 19.1 ml/min/1.73 m(2), median proteinuria was 0.55 and 0.56 g/day, and median urinary red blood cells were 20 (10-20) and 20 (6-30)/high power filed. The histological (H) grade was lower in the CSP than the ISP group (p = 0.022). The remission rate of proteinuria, hematuria, and rate of CR by the Kaplan-Meier method and logrank test were significantly higher in the CSP group than in the ISP group (CSP vs. ISP group; proteinuria: 97.8 vs. 77.3 %, p < 0.001, hematuria: 97.8 vs. 75.0 %, p = 0.005, CR: 95.6 vs. 63.6 %, p < 0.001). In the Cox proportional hazard model (forced entry), SP protocol and proteinuria before treatment were significantly associated with CR [SP protocol: hazard ratio (HR) 2.50, 95 % confidence interval (CI) 1.46-4.30, p = 0.001, proteinuria: HR 0.81, 95 % CI 0.68-0.96, p = 0.013)]. However H-grade was associated with remission of proteinuria (H-grade: hazard ratio (HR) 0.56, 95 % confidence interval (CI) 0.37-0.85, p = 0.006), and this result meant histological bias affected the remission of proteinuria.
The difference of the protocol of TSP therapy may have some effect on the CR of IgAN, though the histological bias was observed in this study. The appropriate protocol and indication of TSP therapy must be analyzed and determined in the randomized controlled trial.
近年来，扁桃体切除术和类固醇脉冲（TSP）治疗在日本已广泛应用。然而，对于治疗方案和适应证尚未达成共识。
在这项回顾性分析中，我们比较了在肾活检后 1 年内，分别接受扁桃体切除术联合间歇性类固醇脉冲（SP）治疗 3 次（ISP 组，n = 44）和连续 3 周接受 SP 治疗（CSP 组，n = 46）的患者。这两种不同的方案在两个不同的机构进行。我们分析了临床和组织学背景以及临床缓解（CR），定义为治疗开始后 18 个月时尿液异常消失。
在治疗前，两组间除性别外，临床发现无显著差异。在 ISP 组和 CSP 组中，估计肾小球滤过率的平均值分别为 82.1 ± 20.9 和 85.9 ± 19.1 ml/min/1.73 m²，中位蛋白尿分别为 0.55 和 0.56 g/天，中位尿红细胞分别为 20（10-20）和 20（6-30）/高倍视野。CSP 组的组织学（H）分级低于 ISP 组（p = 0.022）。CSP 组的蛋白尿、血尿缓解率以及 CR 的 Kaplan-Meier 法和对数秩检验的率均显著高于 ISP 组（CSP 组 vs. ISP 组；蛋白尿：97.8% vs. 77.3%，p < 0.001，血尿：97.8% vs. 75.0%，p = 0.005，CR：95.6% vs. 63.6%，p < 0.001）。在 Cox 比例风险模型（强制进入）中，SP 方案和治疗前蛋白尿与 CR 显著相关[SP 方案：风险比（HR）2.50，95%置信区间（CI）1.46-4.30，p = 0.001，蛋白尿：HR 0.81，95%CI 0.68-0.96，p = 0.013]）。然而，H 级与蛋白尿缓解相关（H 级：HR 0.56，95%CI 0.37-0.85，p = 0.006），这意味着组织学偏倚影响了蛋白尿的缓解。
TSP 治疗方案的差异可能对 IgAN 的 CR 有一定影响，尽管本研究中观察到组织学偏倚。TSP 治疗的适当方案和适应证必须在随机对照试验中进行分析和确定。
