Rondeau E, Kourilsky O, Peraldi M N, Alberti C, Kanfer A, Sraer J D
Service de Néphrologie A, Hôpital Tenon, Paris, France.
Ren Fail. 1993;15(4):495-501. doi: 10.3109/08860229309054964.
In a previous study, we found that aggressive immunosuppressive therapy with continuous high-dose oral steroid and cyclophosphamide combined with plasma exchanges for extracapillary crescentic glomerulonephritis gave controversial results since, although disease activity was controlled, iatrogenic complications had led to death in some aged patients. We then modified our therapeutic regimen, and we analyze here the evolution of 30 consecutive patients who were admitted for biopsy-proven crescentic glomerulonephritis between 1989 and 1991. The mean plasma creatinine level at admission was 393 +/- 59 mumol/L (range 70 to 1100), and 15 patients had crescent formation in more than 50% of glomeruli on initial renal biopsy. Ten patients did not receive any immunosuppressive treatment since they either had a normal renal function or they had terminal renal failure and no severe extrarenal manifestation. The 20 other patients received initial steroid pulses 500 mg x3 (n = 17), low oral steroid treatment (n = 20), cyclophosphamide pulses (n = 13), or oral cyclophosphamide (n = 3). In 4 cases plasma exchanges were also used. As a whole, 10 patients (33%) were discharged with a normal renal function, and 18 patients (60%) had chronic renal failure, 7 of them requiring dialysis or transplantation; only 2 patients died of pulmonary hemorrhage. No severe iatrogenic complication was observed. These results indicate that reduction in oral steroid dosage, cyclophosphamide pulse therapy rather than continuous oral treatment, and plasma exchanges do not induce overimmunosuppression and iatrogenic complication. It can be safe, well tolerated, and as effective as a more intensive immunosuppressive regimen for the treatment of crescentic extracapillary glomerulonephritis.
在之前的一项研究中，我们发现，对于毛细血管外新月体性肾小球肾炎，采用持续大剂量口服类固醇和环磷酰胺联合血浆置换的积极免疫抑制疗法产生了有争议的结果，因为尽管疾病活动得到了控制，但医源性并发症导致一些老年患者死亡。然后我们修改了治疗方案，在此分析1989年至1991年间因活检证实为新月体性肾小球肾炎而入院的30例连续患者的病情演变。入院时平均血浆肌酐水平为393±59μmol/L（范围70至1100），15例患者在初次肾活检时超过50%的肾小球有新月体形成。10例患者未接受任何免疫抑制治疗，因为他们要么肾功能正常，要么处于终末期肾衰竭且无严重肾外表现。其他20例患者接受了初始类固醇冲击治疗500mg×3（n = 17）、低剂量口服类固醇治疗（n = 20）、环磷酰胺冲击治疗（n = 13）或口服环磷酰胺（n = 3）。4例患者还采用了血浆置换。总体而言，10例患者（33%）出院时肾功能正常，18例患者（60%）患有慢性肾衰竭，其中7例需要透析或移植；仅2例患者死于肺出血。未观察到严重的医源性并发症。这些结果表明，减少口服类固醇剂量、采用环磷酰胺冲击疗法而非持续口服治疗以及血浆置换不会导致免疫抑制过度和医源性并发症。对于治疗新月体性毛细血管外肾小球肾炎，它可以是安全的、耐受性良好的，并且与更强化的免疫抑制方案一样有效。
