Comparison between consecutive and intermittent steroid pulse therapy combined with tonsillectomy for clinical remission of IgA nephropathy
Comparison between consecutive and intermittent steroid pulse therapy combined with tonsillectomy for clinical remission of IgA nephropathy
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DOI：
10.1007/s10157-013-0822-8
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发表时间：
2014-04-01
影响因子：
2.3
通讯作者：
Nitta, Kosaku
中科院分区：
文献类型：
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作者：
Kamei, Daigo;Moriyama, Takahito;Nitta, Kosaku
近年来，扁桃体切除术和类固醇脉冲（TSP）疗法在日本得到广泛应用。然而，关于治疗方案和适应症尚未达成共识。在这项回顾性分析中，我们比较了肾活检后1年内接受扁桃体切除术加3次间歇性类固醇脉冲（SP）治疗的患者（ISP组，n = 44）与肾活检后1年内接受扁桃体切除术加连续3周SP治疗的患者（CSP组，n = 46）。这两种不同的方案是在两个不同的机构进行的。我们分析了临床和组织学背景以及临床缓解（CR），定义为开始治疗后18个月尿液异常消失。治疗前，除性别外，两组之间的临床表现没有显着差异。在ISP组和CSP组中，平均估计肾小球滤过率为82.1+/-A 20.9和85.9+/-A 19.1ml/min/1.73m(2)，中位蛋白尿为0.55和0.56g/天，中位尿红细胞为20(10-20)和20(6-30)/高倍视野。 CSP 组的组织学 (H) 等级低于 ISP 组 (p = 0.022)。 CSP 组的蛋白尿、血尿缓解率以及通过 Kaplan-Meier 法和 logrank 检验得出的 CR 率显着高于 ISP 组（CSP vs. ISP 组；蛋白尿：97.8 vs. 77.3 %，p < 0.001，血尿：97.8 vs. 75.0 %，p = 0.005，CR：95.6对比 63.6%，p < 0.001）。在Cox比例风险模型（强制进入）中，SP方案和治疗前蛋白尿与CR显着相关[SP方案：风险比（HR）2.50，95%置信区间（CI）1.46-4.30，p = 0.001，蛋白尿：HR 0.81，95% CI 0.68-0.96，p = 0.013）]。然而，H级与蛋白尿的缓解相关（H级：风险比（HR）0.56，95％置信区间（CI）0.37-0.85，p = 0.006），这一结果意味着组织学偏差影响蛋白尿的缓解。尽管本研究中观察到组织学偏差，但TSP治疗方案的差异可能对IgAN的CR有一定影响。 TSP 治疗的适当方案和适应症必须在随机对照试验中进行分析和确定。
In recent years, tonsillectomy and steroid pulse (TSP) therapy have been widely performed in Japan. However, there is no consensus about the treatment protocol and indication.In this retrospective analysis, we compared patients who received tonsillectomy plus intermittent steroid pulse (SP) therapy three times in 6 months (ISP group, n = 44) with patients who received tonsillectomy plus 3 weeks of consecutive SP therapy (CSP group, n = 46) within 1 year after renal biopsy. These two different protocols were performed at two different institutions. We analyzed the clinical and histological background and clinical remission (CR), defined as disappearance of urine abnormalities at 18 months after starting treatment.Before treatment, there was no significant difference in the clinical findings except for sex between the two groups. In ISP group and CSP group, mean estimated glomerular filtration rate was 82.1 +/- A 20.9 and 85.9 +/- A 19.1 ml/min/1.73 m(2), median proteinuria was 0.55 and 0.56 g/day, and median urinary red blood cells were 20 (10-20) and 20 (6-30)/high power filed. The histological (H) grade was lower in the CSP than the ISP group (p = 0.022). The remission rate of proteinuria, hematuria, and rate of CR by the Kaplan-Meier method and logrank test were significantly higher in the CSP group than in the ISP group (CSP vs. ISP group; proteinuria: 97.8 vs. 77.3 %, p < 0.001, hematuria: 97.8 vs. 75.0 %, p = 0.005, CR: 95.6 vs. 63.6 %, p < 0.001). In the Cox proportional hazard model (forced entry), SP protocol and proteinuria before treatment were significantly associated with CR [SP protocol: hazard ratio (HR) 2.50, 95 % confidence interval (CI) 1.46-4.30, p = 0.001, proteinuria: HR 0.81, 95 % CI 0.68-0.96, p = 0.013)]. However H-grade was associated with remission of proteinuria (H-grade: hazard ratio (HR) 0.56, 95 % confidence interval (CI) 0.37-0.85, p = 0.006), and this result meant histological bias affected the remission of proteinuria.The difference of the protocol of TSP therapy may have some effect on the CR of IgAN, though the histological bias was observed in this study. The appropriate protocol and indication of TSP therapy must be analyzed and determined in the randomized controlled trial.