Hou Wanyin, Yang Haiyan, Chen Pei, Tang Chen, Zhou Xujie, Liu Lijun, Zhu Li, Shi Sufang, Lv Jicheng, Zhang Hong
Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
Department of Nephrology and Rheumatology, Zunyi Hospital of Traditional Chinese Medicine, Zunyi, Guizhou, China.
Clin Kidney J. 2025 Mar 17;18(5):sfaf076. doi: 10.1093/ckj/sfaf076. eCollection 2025 May.
Current proposed KDIGO guidelines suggest systemic corticosteroid therapy to reduce glomerular inflammation in immunoglobulin A nephropathy (IgAN), however the optimal timing for initiating steroid treatment remains a topic of debate. This study evaluates the impact of early versus delayed steroid initiation on long-term outcomes in IgAN patients.
We conducted a retrospective study of 268 IgAN patients treated with corticosteroids for >3 months within 3 years of kidney biopsy. Patients were categorized into early therapy (steroids within 30 days) and delayed therapy (after 30 days). Propensity score matching created matched cohorts. Kaplan-Meier curves and Cox regression assessed outcomes. The primary endpoint was a composite renal outcome [estimated glomerular filtration rate (eGFR) >50% reduction, end-stage kidney disease or renal death]. Secondary endpoints included eGFR decline >30% or >40% and an eGFR slope and time-average proteinuria.
Propensity score matching identified 191 individuals for analysis. The primary outcome was significantly better in the early therapy group, with a hazard ratio (HR) of 0.41 [95% confidence interval (CI) 0.17-0.96, = .041]. Significant benefits were also observed for secondary outcomes, including a lower frequency of >30% and >40% eGFR decline in the early therapy group, with HRs of 0.48 (95% CI 0.24-0.98, = .04) and 0.34 (95% CI 0.14-0.81, = .01), respectively. Cox regression confirmed that the timing of steroid initiation (early vs delayed) was a significant factor associated with kidney progression [HR = 0.33 (95% CI 0.14-0.77), = .01]. The average eGFR slope over 10 years was more favorable in the early therapy group (-1.0 ± 6.0 vs -2.9 ± 6.8 mL/min/1.73 m per year, = .039). No significant differences in baseline characteristics were found to influence the timing of steroid use in progressive IgAN.
Early corticosteroid therapy may help reduce renal decline and preserve long-term kidney function in IgAN patients requiring steroid treatment.
当前拟议的KDIGO指南建议采用全身糖皮质激素疗法来减轻免疫球蛋白A肾病（IgAN）中的肾小球炎症，然而启动类固醇治疗的最佳时机仍是一个有争议的话题。本研究评估了早期与延迟启动类固醇治疗对IgAN患者长期预后的影响。
我们对268例在肾活检后3年内接受糖皮质激素治疗超过3个月的IgAN患者进行了一项回顾性研究。患者被分为早期治疗组（30天内使用类固醇）和延迟治疗组（30天后使用）。倾向评分匹配创建了匹配队列。采用Kaplan-Meier曲线和Cox回归评估预后。主要终点是复合肾脏结局[估计肾小球滤过率（eGFR）降低>50%、终末期肾病或肾脏死亡]。次要终点包括eGFR下降>30%或>40%以及eGFR斜率和时间平均蛋白尿。
倾向评分匹配确定了191例个体进行分析。早期治疗组的主要结局明显更好，风险比（HR）为0.41[95%置信区间（CI）0.17 - 0.96，P = 0.041]。在次要结局方面也观察到显著益处，包括早期治疗组中eGFR下降>30%和>40%的频率较低，HR分别为0.48（95%CI 0.24 - 0.98，P = 0.04）和0.34（95%CI 0.14 - 0.81，P = 0.01）。Cox回归证实，类固醇启动时间（早期与延迟）是与肾脏进展相关的一个重要因素[HR = 0.33（95%CI 0.14 - 0.77），P = 0.01]。早期治疗组10年的平均eGFR斜率更有利（-1.0 ± 6.0对比-2.9 ± 6.8 mL/min/1.73m²每年，P = 0.039）。未发现基线特征的显著差异会影响进行性IgAN中类固醇使用的时间。
早期糖皮质激素治疗可能有助于减少IgAN患者（需要类固醇治疗）的肾脏功能衰退并保留长期肾功能。
