Clinical Characteristics and Outcomes of Immunoglobulin a Nephropathy Patients with Heavy Proteinuria:Therapeutic Roles of Steroids and Renin-Angiotensin System Inhibitors

甲型免疫球蛋白腎病變併重度蛋白尿患者的臨床特色和預後：類固醇和腎素一血管張力素系統抑制劑的治療角色

劉信良(Hsin-Liang Liu) ； 許杏如(Hsin-Ju Sheu) ； 謝日耀(Ryh-Yaw Hsieh) ； 黃建鐘(Jeng-Jong Huang)

《Acta Nephrologica》 16卷2期 (2002/04) Pp. 66-72

摘要

IgA nephropathy (IgAN) is the most common primary glomerulonephritis (GN) worldwide. Although most IgAN patients have a benign course, the natural history of those with heavy proteinuria is quite variable. Several studies show that corticosteroids (steroids) therapy can decrease proteinuria and stabilize the renal function. Also, angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers (ARBs) have the benefit of decreasing proteinuria for IgAN patients with and without hypertension. Because heavy proteinuria is an important poor prognostic factor of IgAN, it is worthy to compare the therapeutic responses of corticosteroids, ACEIs/ARBs, and combined therapy of both agents in these patients with heavy proteinuria (i.e. daily protein loss≧3 g). Therefore, a retrospective study of 102 biopsy-proved IgAN patients was conducted in our hospital. We analyzed the clinical features, laboratory data, and managements by reviewing medical records, and 42 patients were excluded, including loss of follow-up in 26 cases, Henoch-Schonlein purpura in 7, and children in 9. In total, 60 patients with normal renal function were enrolled in this study. Thirty-three of them presented with mild-moderate proteinuria and 27 cases with heavy proteinuria. The heavy proteinuria group shared the similar clinical features with the mild-moderate proteinuria group, but these patients had a more advanced histological changes (i.e. grades III and IV) and higher mean diastolic blood pressure. Among these 27 patients, 8 were treated with steroids, 8 with ACEIs/ARBs, and 6 with combined therapy (i.e. steroids plus ACEIs/ARBs). And the other five patients were excluded due to poor compliance, including one in steroids group, one in ACEIs/ARBs group, and three in combined therapy group. After a follow-up of 40.3±31.9 months, we found that daily protein loss decreased 38% in steroids alone group (P＜0.05), 35% in ACEIs/ARBs therapy group (P＞0.05), and 65% in combined therapy group (P＜0.01). Although there were no significant differences of proteinuria reduction among the three subgroups of IgAN patients with heavy proteinuria, there was no non-responder in combined therapy group. Prospective clinical trials are mandatory to prove the efficacy of steroids plus ACEI or ARB therapy in IgA patients with heavy proteinuria.

關鍵字

甲型免疫球蛋白腎病變 ； 蛋白尿 ； 類固醇 ； 血管張力素轉換酶抑制劑 ； 第二血管張力素受器拮抗劑

並列摘要

IgA nephropathy (IgAN) is the most common primary glomerulonephritis (GN) worldwide. Although most IgAN patients have a benign course, the natural history of those with heavy proteinuria is quite variable. Several studies show that corticosteroids (steroids) therapy can decrease proteinuria and stabilize the renal function. Also, angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers (ARBs) have the benefit of decreasing proteinuria for IgAN patients with and without hypertension. Because heavy proteinuria is an important poor prognostic factor of IgAN, it is worthy to compare the therapeutic responses of corticosteroids, ACEIs/ARBs, and combined therapy of both agents in these patients with heavy proteinuria (i.e. daily protein loss≧3 g). Therefore, a retrospective study of 102 biopsy-proved IgAN patients was conducted in our hospital. We analyzed the clinical features, laboratory data, and managements by reviewing medical records, and 42 patients were excluded, including loss of follow-up in 26 cases, Henoch-Schonlein purpura in 7, and children in 9. In total, 60 patients with normal renal function were enrolled in this study. Thirty-three of them presented with mild-moderate proteinuria and 27 cases with heavy proteinuria. The heavy proteinuria group shared the similar clinical features with the mild-moderate proteinuria group, but these patients had a more advanced histological changes (i.e. grades III and IV) and higher mean diastolic blood pressure. Among these 27 patients, 8 were treated with steroids, 8 with ACEIs/ARBs, and 6 with combined therapy (i.e. steroids plus ACEIs/ARBs). And the other five patients were excluded due to poor compliance, including one in steroids group, one in ACEIs/ARBs group, and three in combined therapy group. After a follow-up of 40.3±31.9 months, we found that daily protein loss decreased 38% in steroids alone group (P＜0.05), 35% in ACEIs/ARBs therapy group (P＞0.05), and 65% in combined therapy group (P＜0.01). Although there were no significant differences of proteinuria reduction among the three subgroups of IgAN patients with heavy proteinuria, there was no non-responder in combined therapy group. Prospective clinical trials are mandatory to prove the efficacy of steroids plus ACEI or ARB therapy in IgA patients with heavy proteinuria.

並列關鍵字

IgA nephropathy ； proteinuria ； angiotensin-converting enzyme inhibitors ； ACEIs ； angiotensin receptor blockers ； ARBs ； corticosteroids ； renal insufficiency