急性感染后新月体肾炎教材

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1、-感染后新月体肾炎温州医学院附属第一医院 陈天新急性感染后肾小球肾炎主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究本例临床特点：上呼吸道感染后（45天）肉眼血尿，大量蛋白尿，浮肿ASO逐渐下降C3逐渐回升 血肌酐升高，在无特殊治疗情况下已逐渐下降9.169.239.269.2810.210.610.710.1310.1810.2010.25C3 g/L0.410.710.670.660.520.620.62ASO（IU/mL）375270

2、2521429690SCr（umol/L）3733122301881971391631671659.27MP冲击急性感染后肾小球肾炎临床诊断：感 染后第19天第31天第40天第46天第51天第58天日期 9.169.2810.710.1310.1810.25 9.27甲强龙冲击甲强龙冲击为什么不诊断为急进性肾炎患者在用激素冲击前肾功能已好转，而不是进行性恶化。因此我认为临床上不符合急进性肾炎。急进性肾炎为急性快速进展性肾小球肾炎（acute rapidly progressive glomerulonephritis，ARPG）的简称。它起病急骤，可在数日、数周或数月内肾功能急剧恶化，以少尿（

3、无尿）性急性肾功能衰竭为多见。急性肾炎综合征进行性肾功能损害。进行性肾功能损害。新月体性肾炎ARPG特征：临床：病理：肾小球弥漫性毛细血管内中重度增生伴毛细血管腔闭塞及多核白细胞滞留典型APGN病理 26个肾小球，7个球性硬化，11个肾小球见大型细胞性新月体。（IF）以IgA及C3沉积最强，呈颗粒状，肾小球毛细血管壁及系膜区分布为主。病理特点结合临床病理，可诊断：感染后新月体肾炎。新月体肾炎急进性肾炎感染后新月体肾炎比较少见（占肾活检标本4.6）相比而言，老年人易出现感染细菌：链球菌，金黄色葡萄球菌，革兰氏阴性杆菌等。An update on acute postinfectious glom

4、erulonephritis worldwide.Kanjanabuch, T. et al. Nat. Rev. Nephrol. 5, 259269 (2009)感染后肾炎绝大部分未行肾活检活检时机和指征不一样，新月体比例也不一样因此，确切的发病率无法统计和报道主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究Pediatrics 1975Pediatrics 1975 新月体肾炎例数新月体肾炎例数链感后链感后随访随访预后预后1717101018 to 57 18 to 57 monthsmonths链感

5、后预后较好链感后预后较好The Journal of Pediatrics 1981链感后新月体肾炎链感后新月体肾炎 pre+ctx/azapre+ctx/aza支持治疗支持治疗预后预后1010例（例（CcrCcr30)50%;IF:50%;IF:IgAIgA,C3.,C3.抗感染后抗感染后4 4例好转，例好转，1HD, 1HD, 2 2例用例用激素后感染再发死亡激素后感染再发死亡Kidney Kidney Int.Int. 191995 95 Jan;47Jan;471010MASRMASRabrupt or insidious onset of RPGN1例例proliferative G

6、N 伴新月体，伴新月体，4例例未活检未活检2HD,1CRF,5CRI,22HD,1CRF,5CRI,2恢复恢复ClinClin NephrolNephrol. . 1997,481997,481 1MASAMASAproteinuria and renal dysfunction minor to mild MsPGNHUMAN HUMAN PATHOLOGY PATHOLOGY 2003,342003,345 5葡萄葡萄球菌球菌ARF(基础病基础病2-DM，DN)IF:IgA， C3为主，为主，未提及新月体未提及新月体4 4例例HD,1HD,1例部分恢复例部分恢复Human Human Pa

7、thology Pathology (2008) 39(2008) 391313葡萄葡萄球菌球菌ARIIF:IgA， C4为主，为主，未提及新月体未提及新月体4 4例有基础例有基础CRICRI进入进入ESRD,ESRD,7 7例肾功能好转例肾功能好转Longterm prognosis of diffuse proliferative glomerulonephritis associated with infection in adultsGabriella Moroni 1 , Claudio Pozzi 2 , Silvana Quaglini 3 , Nephrol. Dial. Tr

8、ansplant.-2002病例入选标准：临床生化和病理标准至少各2条Clinical/biochemical criteria included (i) a recent episode of infection, (ii) antistreptolysin O titre 250IU/l(iii) a transient reduction of serum complement fractions.Histological criteria included(i) diffuse proliferative and/or exudative glomerulonephritis, (ii

9、) dominant granular immunedeposits of IgG and/or C3 in the subepithelial position at immunofluorescence (cases with faint deposits of IgA were included according to Silva 7) (iii) presence of humps on electron microscopy.Exclusion criteria were:predominant IgA deposits on immunofluorescence; idiopat

10、hic membranoproliferative glomerulonephritis; cryoglobulinaemic nephritis; lupus nephritis.The infective agents cultured from the sites of infection :Streptococcus haemolyticus (5 patients), Staphylococcus aureus (6 patients), Escherichia coli (8 patients), Pseudomonas aeruginosa (绿脓杆菌2 patients), H

11、aemophilus influenzae (嗜血杆菌1 patient). 21 of the 45 patients evaluated had high antistreptolysin titre.Clinical characteristics of patients at presentationGroup 1 (29 patients)Group 2 (21 patients)P TotalAge (years)47 (1862)62 (4870)0.0154 (3066)Sex (M/F)14/1516/5n.s.30/20Plasma cre (mg/dl)1.5 (14)3

12、.0 (1.44.3)n.s.2.15 (1.24.1)Proteinuria (g/24h)3.5 (0.76.1)7.1 (2.511.5)0.053.7 (1.89)hypertension19 (68%)14 (67%)n.s.33steroid therapy（n）1311Group 1： APIGN without other underlying disease (29 patients). Group 2 :APIGN with severe underlying disease (21 patients), 9 liver cirrhosis, 4 malignant neo

13、plasia,5 DM（其中3例有肝硬化）, 3 COPD, 1 地中海贫血，1肌炎，1磷脂抗体综合征。Main findings at renal biopsyGroup 1Group 2P Total (%)Light microscopy (number of patients)292150 (100)Endocapillary proliferation291848 (96)Membranoproliferative022 (4)Crescents in 30% of glomeruli7110.0718 (36)Glomerular fibrinoid necrosis44n.s.8

14、 (16)Interstitial infiltration (2+ or 3+)8160.0118 (36)Vascular fibrinoid necrosis12n.s.3 (6)C3 (2+ or 3+)291847 (94)IgG (2+ or 3+)188n.s.26 (52)IgM (1+)6130.0119 (38)C1q (1+)63n.s.9 (18)IgA (1+)590.0914 (28)Starry sky pattern14620 (40)Garland pattern213 (6)Mesangial pattern112 (4)Renal status of 49

15、 patients at the last observationGroup 1Group 2TotalComplete remission (number of patients)18 (64%)3 (14%)21 (43%)Followup (months)145 (55219)54 (5262)138 (60211)Partial remission (n)5 (18%)5 (24%)10 (20%)Followup (months)20 (1299)31 (1853)38 (21107)Plasma creatinine (mg/dl)1 (0.91.1)1.2 (0.71.3)1 (

16、0.91.2)Proteinuria (g/24h)1 (0.82.4)1 (0.82)1 (0.62)Microscopic haematuria（n）459Renal insufficiency (n) 3 (11%)9 (43%)13 (27%)Followup (months)46, 175, 18036 (948)46 (12110)Plasma creatinine (mg/dl)1.5, 1.9, 2.42 (1.72.4)1.9 (1.72.4)Proteinuria (g/24h)0.5, 0.9, 2.41 (0.51.5)1 (0.52)Microscopic haema

17、turia (n)21012dialysis(number of patients) 2 (7%)3 (14%)5 (10%)Followup (months)1, 32, 2, 62 (23)Remission (21)No remission (28)PAge (years, median)47 (1758)63 (4268)0.08Underlying diseases (%)14.364.30.01Proteinuria (g/24h, median)3.7 (0.76)4.7 (2.310.3)0.06Extracapillary proliferation (%)14610.03I

18、nterstitial infiltration (%)5570.017Subendothelial deposits on electron microscopy (%)19680.05Clinical and histological predictors of complete remission: univariate analysis At multivariate analysis only the absence of an underlying disease, (P=0.04) and the absence of interstitial infiltration (P=0

19、.036) were predictive of complete remission. The relative risk of incomplete recovery were 3.5 (95% CI, 1.0312.2) and 8.7 (95% CI, 1.1565.5). this study shows that infectionassociated glomerulonephritis should be considered a serious disease in adults, particularly when there is a previous disease a

20、nd/or when it is associated with severe interstitial infiltration at renal biopsy. Even in favorable cases recovery may require several months. Patients with incomplete recovery should be regularly monitored as many of them may progress to chronic renal insufficiency. The treatment with steroids did not improve the outcome; rather it was associated with a worse prognosis. In conclusion,