Clinical effectiveness of steroid pulse therapy combined with tonsillectomy in patients with immunoglobulin A nephropathy presenting glomerular haematuria and minimal proteinuria
Clinical effectiveness of steroid pulse therapy combined with tonsillectomy in patients with immunoglobulin A nephropathy presenting glomerular haematuria and minimal proteinuria
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DOI：
10.1111/j.1440-1797.2009.01147.x
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发表时间：
2010-02-01
期刊：
影响因子：
2.5
通讯作者：
Hotta, Osamu
中科院分区：
文献类型：
--
作者：
Kawaguchi, Takehiko;Ieiri, Norio;Hotta, Osamu
目的：类固醇冲击疗法联合扁桃体切除术 (ST) 已在患有中度或重度泌尿系统异常的免疫球蛋白 A 肾病 (IgAN) 患者中显示出有效性。本研究旨在阐明其有效性是否可以外推至伴有轻微泌尿异常的 IgAN，以及有效性是否可能取决于伴有轻微泌尿异常的组织学严重程度。 方法：分析了 1987 年至 2000 年仙台 Shakaihoken 医院通过肾活检诊断的 388 名 IgAN 患者的数据，这些患者在基线时出现肾小球血尿和少量蛋白尿（< 0.5 g/天）。 Cox 回归用于检查 ST 基线使用与随后的临床缓解 (CR) 之间的关联，临床缓解 (CR) 定义为试纸检测阴性蛋白尿和尿红细胞低于 1/高倍视野。还使用工具变量方法来克服治疗适应症的混杂因素。结果：在中位随访 24 个月期间，我们观察到 170 例 CR 病例。接受 ST 的患者更年轻，并且表现出更好的病例组合特征。在未经调整的模型（风险比 (HR) = 5.51，95% 置信区间 (CI) = 3.33-9.12，P < 0.001）或调整的 Cox 模型（HR = 4.65，95% CI = 2.43-8.88，P < 0.001）中，ST 患者的 CR 率显着高于未接受扁桃体切除术或类固醇脉冲的患者。 ST 组中不太严重的组织学结果与较高的 CR 率显着相关。通过治疗适应症调整混杂因素后显示，ST 的效果减弱但仍然显着（HR = 3.10，95% CI = 2.02-4.77，P < 0.001）。结论：ST 显着增加了肾小球血尿和少量蛋白尿的 IgAN 患者的 CR 概率，并且对于组织学结果不太严重的患者更有效。
Aim: The effectiveness of steroid pulse therapy combined with tonsillectomy (ST) has been shown in immunoglobulin A nephropathy (IgAN) patients with moderate or severe urinary abnormalities. The present study aimed to clarify whether the effectiveness may be extrapolated to IgAN with minor urinary abnormalities, and whether the effectiveness may depend on the histological severity with minor urinary abnormalities.Methods: Data on 388 IgAN patients diagnosed by renal biopsies between 1987 and 2000 in Sendai Shakaihoken Hospital, who presented glomerular haematuria and minimal proteinuria (< 0.5 g/day) at baseline, were analyzed. Cox regression was used to examine associations between baseline use of ST and subsequent clinical remission (CR), defined as negative proteinuria by dipstick and urinary erythrocytes of less than 1/high-power field. The instrumental variable method was also used to overcome confounding by treatment indication.Results: During a median follow up of 24 months, we observed 170 CR cases. Patients receiving ST were younger and showed a better case-mix profile. Patients with ST had a significantly higher rate of CR than patients without tonsillectomy or steroid pulse in an unadjusted (hazard ratio (HR) = 5.51, 95% confidence interval (CI) = 3.33-9.12, P < 0.001) or adjusted Cox model (HR = 4.65, 95% CI = 2.43-8.88, P < 0.001). Less severe histological findings were substantially associated with higher CR rate in ST group. Adjusting for confounding by treatment indication showed an attenuated but still significant effect of ST (HR = 3.10, 95% CI = 2.02-4.77, P < 0.001).Conclusion: ST significantly increased the probability of CR in IgAN patients with glomerular haematuria and minimal proteinuria, and it was more effective in those with less severe histological findings.