Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan.
PLoS One. 2018 Jun 18;13(6):e0199228. doi: 10.1371/journal.pone.0199228. eCollection 2018.
In patients with adult minimal change disease (MCD), proteinuria relapse is a problem to solve. However, the optimal relapse treatment regimen remains unclear regarding steroid dose. We described the treatment pattern of adult MCD patients and evaluated the appropriate steroid dose for relapse treatment.
This retrospective multicenter cohort study included 192 patients with adult biopsy-proven MCD from 14 hospitals in Japan. The prescription pattern of immunosuppressive drugs in relapse was reviewed. To assess the association between steroid dose used for relapse and subsequent outcomes, data of patients with tapered prednisolone (PSL) dosage to <10 mg/day before the first relapse in whom the dose was subsequently increased to ≥10 mg/day were extracted and assigned to the High-PSL or Low-PSL groups, based on the median dose of 20 mg/day. Multivariate Cox proportional hazard model and propensity score analysis with multiple imputations were conducted to compare their clinical course.
During a median observation period of 37.6 months, 186/192 (96.9%) patients achieved complete remission (CR) and 100 (52.1%) relapsed. The median urinary protein level at the first relapse was 3.12 g/gCr or g/day. The proportion of non-steroidal immunosuppressant use increased with relapses; cyclosporine was the most common. No significant differences were found in the second relapse, frequent relapses, or adverse events between High-PSL (n = 34) and Low-PSL (n = 36) groups. A multivariate Cox proportional hazard model revealed that the hazard ratios adjusted with propensity score for the second relapse were 0.94 (High-PSL vs. Low-PSL; 95% confidence interval, 0.42-2.10; P = 0.88) and 0.82 (PSL dose per 10 mg/day; 95% confidence interval, 0.58-1.16; P = 0.25).
Among patients in CR with PSL dose <10 mg/day, higher steroid dose (PSL >20 mg/day) was not associated with favorable outcomes after the first relapse as compared to lower dose (10-20 mg/day).
在成人微小病变性肾病（MCD）患者中，蛋白尿复发是一个亟待解决的问题。然而，对于复发的治疗方案，类固醇剂量的最佳方案仍不明确。我们描述了成人 MCD 患者的治疗模式，并评估了复发治疗中适当的类固醇剂量。
本回顾性多中心队列研究纳入了来自日本 14 家医院的 192 例经活检证实的成人 MCD 患者。回顾了复发时免疫抑制剂的处方模式。为了评估复发时使用的类固醇剂量与后续结局之间的关系，我们提取了在首次复发前泼尼松龙（PSL）剂量逐渐减少至<10mg/天且随后增加至≥10mg/天的患者的数据，并根据 20mg/天的中位数剂量将其分为高 PSL 或低 PSL 组。采用多变量 Cox 比例风险模型和倾向性评分分析（采用多重插补法）来比较两组的临床病程。
在中位观察期 37.6 个月期间，186/192（96.9%）例患者达到完全缓解（CR），100（52.1%）例患者复发。首次复发时尿蛋白水平的中位数为 3.12g/gCr 或 g/天。随着复发次数的增加，非甾体类免疫抑制剂的使用比例增加，环孢素是最常用的药物。在第二次复发、频繁复发或不良事件方面，高 PSL（n=34）和低 PSL（n=36）组之间未发现显著差异。多变量 Cox 比例风险模型显示，经倾向性评分调整后的第二次复发风险比为 0.94（高 PSL 与低 PSL；95%置信区间，0.42-2.10；P=0.88）和 0.82（PSL 剂量每增加 10mg/天；95%置信区间，0.58-1.16；P=0.25）。
在 PSL 剂量<10mg/天且处于 CR 状态的患者中，与低剂量（10-20mg/天）相比，较高的类固醇剂量（PSL>20mg/天）与首次复发后的良好结局无关。
