双重血浆置换联合免疫抑制剂治疗重症狼疮性肾炎的疗效

doi:10.3969/j.issn.1006-298X.2019.01.003

肾脏病与透析肾移植杂志 ›› 2019, Vol. 28 ›› Issue (1): 13-18.DOI: 10.3969/j.issn.1006-298X.2019.01.003

双重血浆置换联合免疫抑制剂治疗重症狼疮性肾炎的疗效

出版日期:2019-02-28 发布日期:2019-03-04

Outcome of severe lupus nephritis treated by double filtration plasmapheresis combined with immunosuppressants

Online:2019-02-28 Published:2019-03-04

摘要/Abstract

摘要：

目的：观察分析双重血浆置换（DFPP）联合免疫抑制剂治疗重症狼疮性肾炎（LN）的临床疗效及肾脏远期预后的影响因素。
方法：回顾性分析2009年7月～2017年9月在国家肾脏疾病临床医学研究中心住院接受DFPP治疗的重症LN患者61例（男性22例、女性39例），平均年龄236岁，系统性红斑狼疮疾病活动指数（SLEDAI） 183±50分，血清肌酐（SCr） 3156(2095,5340) μmol/L，37例(607%)表现为急进性肾炎，34例(557%)需行即时肾脏替代治疗。这些患者均接受肾活检，病理类型以Ⅳ型（36例）和Ⅴ+Ⅳ型（17例）为主，29例合并血栓性微血管病（TMA）。DFPP采用EC50W和 EC20W作为血浆分离器，每次处理2倍血浆容量。这些患者均接受甲泼尼龙静脉冲击（05 g/d×3～6d），后续口服激素联合免疫抑制剂治疗。观察治疗后SLEDAI和SCr变化、3个月摆脱透析患者比例,分析肾脏远期预后及其影响因素。
结果：DFPP治疗26±07次后，SLEDAI和SCr明显下降，dsDNA滴度下降；治疗3个月，尿检及血清学指标明显改善，588%（20/34）需即时透析的患者摆脱透析；3例患者失访,平均随访423月，19例进入终末期肾病，21例完全缓解，15例部分缓解；多因素COX回归分析发现慢性化指数（CI）（HR=131，95%CI 106～162）和起病时SCr（HR=2665，95% CI 332～21370）是影响肾脏存活的独立危险因素；DFPP治疗后4例出现感染，2例凝血功能异常。
结论：DFPP联合免疫抑制剂治疗能快速清除自身抗体，缓解狼疮活动，改善肾功能；总缓解率和肾存活率相对较高，CI和起病时SCr是影响肾存活的独立危险因素。DFPP联合免疫抑制剂是治疗重症LN的一种有效手段。

关键词: 狼疮性肾炎, 双重血浆置换, 临床疗效, 肾脏预后, 危险因素

Abstract:

Ｏｂｊｅｃｔｉｖｅ：To investigate the longterm outcomes of double filtration plasmapheresis （DFPP） combined with immunosuppressants in patients with severe lupus nephritis（LN）.
Ｍｅｔｈｏｄｏｌｏｇｙ：Sixty one severe LN patients (39 females and 22 males，median age 236 years with biopsy proven ( mainly class Ⅳ and Ⅴ+Ⅳ) from July 2009 to September 2017 were enrolled in the study.Among them，37(607%) patients showed rapidly progressive glomerulonephritis and 34(557%) needed renal replacement therapy at baseline with SLEDAI 183±50,SCr 3156(2095,5340) μmol/L，29 patients had thrombotic microangiopathy (TMA) lesions.DFPP was performed with twofold plasma volume on each session using membrane type plasma component separator (EC50W and EC20W).All patients were given intravenous methylprednisolone (05 g/d×3～6d) and followed by glucocorticoids combined with immunosuppressants.The changes of SLEDAI and SCr after DFPP treatment,the ratio of patients free from dialysis at 3 months,the longterm efficacy and risk factors of renal survival were analyzed.
Ｒｅｓｕｌｔｓ：After DFPP treatment of 26±07 times,SLEDAI and SCr were decreased significantly with the titer of dsDNA.When treated for 3 months,urine analysis and serological indicators were further improved.588% (20/34) patients who needed renal replacement therapy at baseline were free from dialysis.3 patient were lost to followup.When followed up for 423 months,there were 19 patients entered end stage renal disease,21 patients achieved complete remission and 15 had partial remissionMultiple factor COX regression analysis found that chronicity index (CI) (HR=131,95% CI 106162) and baseline SCr (HR=2665,95% CI 33221370) were independent risk factors for the renal survivalDuring DFPP treatment, 4 patients had infections and 2 patients experienced coagulation dysfunction.
Ｃｏｎｃｌｕｓｉｏｎ：
DFPP combined with immunosuppressants can quickly remove autoantibodies,relieve lupus activity and improve renal function.The longterm remission rate and renal survival rate were relatively high.CI and baseline SCr were independent risk factors for renal survivalDFPP combined with immunosuppressants is an effective method for severe LN therapy.

Key words: lupus nephritis, double filtration plasmapheresis, clinical efficacy, renal outcome, risk factor

章海涛，周敏林，代敏，等. 双重血浆置换联合免疫抑制剂治疗重症狼疮性肾炎的疗效[J]. 肾脏病与透析肾移植杂志, 2019, 28(1): 13-18.

ZHANG Haitao，ZHOU Minlin,DAI Min, et al. Outcome of severe lupus nephritis treated by double filtration plasmapheresis combined with immunosuppressants[J]. Chinese Journal of Nephrology, Dialysis & Transplantation, 2019, 28(1): 13-18.

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ISSN 1006-298X CN 32-1425/R

双重血浆置换联合免疫抑制剂治疗重症狼疮性肾炎的疗效

Outcome of severe lupus nephritis treated by double filtration plasmapheresis combined with immunosuppressants

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