Chan Chieh Kai, Lai Tai Shuan, Chen Ping Min, Chou Yu Hsiang, Wu Ching Fang, Chiu Yen Ling, Chiang Wen Chih, Chen Yung Ming, Chu Tzong-Shinn, Wu Kwan Dun
Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin Chu County, Taiwan.
Department of Internal Medicine, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.
J Formos Med Assoc. 2017 Apr;116(4):266-275. doi: 10.1016/j.jfma.2017.01.004. Epub 2017 Feb 13.
BACKGROUND/PURPOSE: Suggestion for the management of idiopathic membranous nephropathy (IMN) includes 6 months of observation, followed with steroid plus alkylating agent. However, delayed immunosuppression exposes the kidneys to persistent damage. This study aimed to examine the benefit of early immunosuppression in IMN patients.
A retrospective study was performed. From 1993 to 2013, 161 IMN patients were enrolled. Patients receiving immunosuppression within 6 months after diagnosis were classified as initial-treatment group, whereas other patients as initial-no-treatment group. The clinical outcomes and complication were examined.
Patients in the initial-treatment group had lower serum albumin concentration, less diabetes, and were younger. Steroid monotherapy is the main immunosuppression (64.5%) in this group. The initial-treatment group had a higher complete and partial remission rate than the initial-no-treatment group 6 months (52.9% vs. 35.0%, p=0.05) and 12 months (71.1% vs. 45.0%, p=0.003) after diagnosis. A similar result was seen between initial-steroid monotherapy and initial-no-treatment patients. Early immunosuppression is an independent predictor of remission within 1 year [hazard ratio (HR)=2.09; 95% confidence interval (CI)=1.25-3.49; p=0.005] and estimated glomerular filtration rate (eGFR) decline over 50% during the follow-up. (HR=0.33; 95% CI=0.13-0.86; p=0.02). The initial-treatment group also had a low frequency of eGFR decline over 50% (p=0.001) and low combined end-stage renal disease/mortality (p=0.001) compared with the initial-no-treatment group, but without more immunosuppression-related complication.
In contrast to Western countries, early immunosuppression (even steroid monotherapy) in our patients is associated with better remission in the 1 year and renal preserve. Further randomized controlled trials are needed to clarify the benefit of early immunosuppression in IMN patients, especially with oriental ethnic background.
背景/目的：特发性膜性肾病（IMN）的管理建议包括6个月的观察期，随后使用类固醇加烷化剂。然而，延迟免疫抑制会使肾脏持续受损。本研究旨在探讨早期免疫抑制对IMN患者的益处。
进行了一项回顾性研究。1993年至2013年，共纳入161例IMN患者。诊断后6个月内接受免疫抑制治疗的患者被归类为初始治疗组，其他患者为初始未治疗组。检查临床结局和并发症。
初始治疗组患者的血清白蛋白浓度较低，糖尿病患者较少，且年龄较小。类固醇单药治疗是该组主要的免疫抑制方法（64.5%）。诊断后6个月（52.9%对35.0%，p=0.05）和12个月（71.1%对45.0%，p=0.003）时，初始治疗组的完全缓解率和部分缓解率均高于初始未治疗组。初始类固醇单药治疗患者与初始未治疗患者之间也观察到类似结果。早期免疫抑制是1年内缓解的独立预测因素[风险比（HR）=2.09；95%置信区间（CI）=1.25-3.49；p=0.005]，也是随访期间估计肾小球滤过率（eGFR）下降超过50%的独立预测因素（HR=0.33；95%CI=0.13-0.86；p=0.02）。与初始未治疗组相比，初始治疗组eGFR下降超过50%的频率也较低（p=0.001），终末期肾病/死亡率合并发生率也较低（p=0.001），但免疫抑制相关并发症并未增多。
与西方国家不同，我们的患者早期免疫抑制（即使是类固醇单药治疗）与1年内更好的缓解率及肾脏保护相关。需要进一步的随机对照试验来阐明早期免疫抑制对IMN患者的益处，尤其是对具有东方种族背景的患者。
