Prognostic Analysis And Clinical Control Study Of Idiopathic Membranous Nephropathy

Background and Objective: Course of idiopathic membranous nephropathy (IMN) is long .Pathogeneticcondition is easily relapse, and Prognosis is different. There are two tendency about IMN. One is spontaneous remission, the other gradually get to renal failure stage. About therapeutics of IMN, time of treatment is longer, sensitiveness is different, and there is a lot of side effects. There is no optimal therapeutics hitherto because the pathomechanism has not been identify. Inorder to improve diagnosis and therapy, to identify the clinical feature and prognosis of IMN and to rationally use the immunosuppressant, we approached its clinical feature and prognostic factors to summarize the case of IMN, and observed the new immune depressant with few side effects to find the new direction for treatment.Methody:(一) The clinical character and prognostic analysis of idiopathic membranous nephropathy.257 patients with IMN were recruited in our hospital, diagnosed as IMN by renal biopsy and excluded the secondary MN caused by infection (hepatitis B, hepatitis C or HIV infection),autoimmune diseases, malignancies, drugs and familial or metabolism factors. Follow up after post-discharge. The data of the patients were collected, database software and statistic method were used to compare the general character, pathological stage, clinical manifestation, laboratory findings and prognostic factors.(二) Leflunomide versus Mycophenolate mofetil for idio-membranous nephropathy43 IMN patients after renal biopsy, were treated with leflunomide (LEF = 23)or mycophenolate mofetil(MMF=20), they were chosen. (1)according to the criteria of Ehrenreich.(2) CTX or other immunosuppressive agent were not used in 3 months.(3) LEF or MMF were used more than 6 months.(4) the patients have used CCB orβ-blocker with hypertension can be chosed. The ACEI or ARB were used more than 4 months before the immunosuppressive agent were used can be selected still. The LEF were administered at the dose of 30 mg/d, qd for at least 6 months. MMF were administered at the dosage of 1.5 g/d in MMF group. Prednisone was gived at the dosage of 0.6～0.8 mg/(kg·d) in two groups. After 6～8 weeks, the dosage of prednisone were declined at the velocity of 5mg/4 weeks until stop it .The results of blood routine, urine routin, 24 hours urine protein quantitation, plasma- album, Scr, etc were colleted before and afeter 6 monthes' treatment. The side effects were recorded at the same time.(三) The control study about Tacrolimus versus Leflunomide for idio-membranous nephropathy39 IMN patients after renal biopsy were be treated with Tacrolimus(FK506) or LEF. Patients were choosen: (1)according to the criteria of Ehrenreich, (2) nephrotic syndrome, (3)Scr<2.5mg/dl (221μmol/L) ,(4)18-70 years old, (5) birth control. Exclusion criteria: (l)accept cytotoxic drug or immunosuppressant in 3 months,(2) complicate other serious kidney disease ,(3) complicate other serious infection ,(4) HBsAg,HBeAg,HBcAb masc, HCV masc, higher aminopherase, (5) malignant tumor, HIV (6) FBS >6.2mmol/L ,(7) cyesis or inleakage, (8) hypersensitiveness for macrocyclic lactone. Choose patients randomly, Tacrolimus was administered at the dosage of 0.1mg/kg/d, blood drug level is 5～10ng/ml; LEF is gived at the dose of 50 mg/d×3 days, then 30mg were given per day; prednisone is gived at the dosage of 0.5 mg/(kg·d) in two groups. After 8 weeks, the dosage of prednisone are declined at the velocity of 5mg/4 weeks until stop it. The result of blood routine, urine routin, 24 hours urine protein quantitation, blood album, Scr, etc are colleted .Results:(一) The clinical character and prognostic analysis of idiopathic membranous nephropathy. (1) The average age of onset in male was higher than that of female. In patients over the age of 50, the proportion of male is higher. (2)One hundred and thirty-six patients (52.9%) presented nephritic syndrome. Hypertension was found in 90 out of 257 patients. Renal insufficiency occurred in 3.1% of the patients at the time of renal biopsy. Microscopic hematuria was found in 24.5% of them. (3)Most of the pathological stage are I,II, the immunofluorescence microscopy showed the main electron dense deposits were IgG and C₃ .The stage was higher, the course was longer. (4)Along with the urine protein increasing, the blood pressure,CH are elevated, Alb are decreased.(5)One of them had deterioration of renal function during the mean period of 34 months follow-up. (6) Scr can predict deterioration of renal function.(二) Leflunomide versus Mycophenolate mofetil for idio-membranous nephropathy(1) The entirety remission rate was 40% and 30.43% respectively in MMF group and LEF group, part remission rate was 45% and 39.13% respectively, there was any discrepance between them. (2) The change of urine protein and plasma-album: Urine protein decreasing and plasma-album rising are occurrenced in two groups. There was any discrepance in the same group. The ascendant amplitude of MMF group exceed than that of LEF group. (3) side effets: there were light rised of ALT level in 2 cases, 1 light alopecie in LEF group, there were light diarrhea in 1 cases in MMF group.(三) The control study about Tacrolimus versus Leflunomide for idio-membranous nephropathy(1) There was any discrepance between cumulative remission rate of two groups. (2) Average time of emerging effect respectively was 7.73 weeks and 11.73 weeks (p<0.01). (3) Side effets: there were light rised of ALT level in 2 cases, 2 hyperglycemia in FK506 group. One of them was draw back. There were light rised of ALT level in 2 cases, 1 light diarrhea in LEF group.Conclusion: 1. We find that the ratio of male patients with IMN is higher than women. The incidence of hypertension, microscopic hematuria and renal insufficiency is similar to that of other countries. Second, the pathological stage is associated with the course of disease. Scr can predict deterioration of renal function.2. There were similar therapy effect and tolerance between predonison combine LEF and MMF in the treatment of IMN. But there was dominance in MMF group on rising plasma-album.3. There was higher clinical remission rate in FK506 group. And average time of emerging effect was shorter, there was a light side effect. But sample is small. So, it is nessary to continue to follow-up.