THE PROGNOSIS OF LUPUS NEPHRITIS IN AFRICAN-AMERICANS - A RETROSPECTIVE ANALYSIS
THE PROGNOSIS OF LUPUS NEPHRITIS IN AFRICAN-AMERICANS - A RETROSPECTIVE ANALYSIS
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DOI：
10.1016/s0272-6386(12)80177-6
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发表时间：
1994-08-01
影响因子：
13.2
通讯作者：
DUNEA, G
中科院分区：
文献类型：
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作者：
BAKIR, AA;LEVY, PS;DUNEA, G
为了全面描述非裔美国人中狼疮性肾炎的临床过程，我们报告了14年来在市中心一家大型医院就诊的54名患者的经验。将患者分为5个组织病理学组。MES组(n=3)为系膜肾炎(WHO II级)，FOC组(n=11)为轻、中度局灶性节段性增生性肾小球肾炎(WHO III级)。DIF组(n=9)包括重度节段性、弥漫性、膜性、膜性和重度重叠增生性病变(WHO III、IV和VD级)。CRES组(n=9)合并40%以上肾小球内有细胞新月体的患者，包括WHO III级(重度)、IV级和VC级和d级患者。MEM组(n=22)为单发或合并系膜或轻度节段性增生性病变(WHO Va和b级)的膜性肾炎。DIF组和CRES组接受大剂量泼尼松和细胞毒药物强化治疗。FOC组和MEM组接受了较小剂量的泼尼松，但有一半的患者后来接受了强化治疗，主要是因为严重的全身症状。MES组3例患者均恢复良好。DIF+CRES组18例患者中有11例发生终末期肾功能衰竭(ESRF)，MEM组22例中有2例发生终末期肾功能衰竭。FOC组11例死亡3例，DIF和CRES组5例死亡，MEM组1例死亡。5年和10年生存率FOC分别为78%和78%，DIF和CRES分别为80%和0%，MEM分别为100%和100%(P<；0.03vDIF/CRES)。无ESRF的5年和10年生存率FOC分别为78%和78%，DIF和CRES分别为52%和0%(P<0.05)，MEM分别为94%和85%(P=0.002vDIF/CRES)。单因素比例风险回归分析显示，ESRF与严重的血小板减少(P=0.003.0 5)、入院时血肌酐>1.4 mg/dL(P=0.0 4)和严重的全身症状(P=0.0 5)显著相关。在控制了组织病理学组后，通过单变量(P=0.01)和多变量(风险比=14.19，P=0.05)分析，只有血小板减少与ESRF密切相关。我们得出结论，非裔美国人的严重增生性狼疮性肾炎预后很差。对于轻、中度局灶性增生性肾炎和无并发症的膜性狼疮性肾炎，预后与白人患者相同。严重的血小板减少预示终末期肾衰。
To fully describe the clinical course of lupus nephritis in an African-American population, we report our experience with 54 patients seen at a large inner-city hospital over a period of 14 years. The patients were divided into five histopathologic groups. Group MES (n = 3) represented mesangial nephritis (World Health Organization [WHO] class II) and group FOC (n = 11) represented mild and moderate focal segmental proliferative glomerulonephritis (WHO class III). Group DIF (n = 9) included patients with severe segmental proliferative, diffuse proliferative, membranoproliferative, and membranous and severe superimposed proliferative lesions (WHO classes III, IV, and Vd). Group CRES (n = 9) combined all the patients with cellular crescents in more than 40% of the glomeruli and included patients in WHO classes III (severe), IV, and Vc and d. Group MEM (n = 22) represented membranous nephritis occurring alone or with superimposed mesangial or mild segmental proliferative lesions (WHO class Va and b). Groups DIF and CRES received intensive treatment with high-dose prednisone and cytotoxic drugs. Groups FOC and MEM received lower doses of prednisone, but half of the patients later received intensive treatment largely for severe systemic manifestations. The three patients in group MES remained well. End-stage renal failure (ESRF) developed in 11 of 18 patients in groups DIF and CRES combined, and in two of 22 patients in group MEM. Three of 11 patients in group FOC, five in groups DIF and CRES, and one in group MEM died. The actuarial 5- and 10-year survival rates were, respectively, 78% and 78% for FOC, 80% and 0% for DIF and CRES, and 100% and 100% for MEM (P< 0.03vDIF/CRES). Fiveand 10-year survival rates without ESRF were, respectively, 78% and 78% for FOC, 52% and 0% for DIF and CRES (P< 0.05), and 94% and 85% for MEM (P= 0.002vDIF/CRES). Univariate proportional hazards regression analysis, uncontrolled for histopathologic groups, showed a significant association between ESRF and severe thrombocytopenia (P= 0.003), serum creatinine above 1.4 mg/dL at entry (P= 0.04), and severe systemic manifestations (P= 0.05). After controlling for histopathologic groups, only thrombocytopenia remained strongly associated with ESRF, both by univariate (P= 0.01) and multivariate (hazard ratio =14.19,P= 0.05) analyses. We conclude that severe proliferative lupus nephritis in African-Americans has a poor prognosis. For mild and moderate focal proliferative nephritis and uncomplicated membranous lupus nephritis the prognosis is as good as in white patients. Severe thrombocytopenia predicts ESRF.