| BackgroundImmunoglobulin A nephropathy (IgAN) is a kind of primary glomerular disease characterized by mesangial proliferation and IgA deposition, which has a wide spectrum of clinical manifestations and different progression levels. The initial renal function, pathological grading, urine protein level and the blood pressure level could be used in the assessment of IgAN progression risk. So far the diagnosis of IgAN rely on the renal biopsy. The alteration of renal biopsy indication may influence the spectrum of disease prognosis and treatment strategy. There is no agreement on the IgAN therapy options so far, and the clinical recommends by KDIGO is based on the lower-level clinical evidence. The treatment strategy for IgAN is affected by various factors. The remission of IgAN has a significant influence on renal prognosis, but the relationship between early treatment response and disease remission is still poorly understood. The tripterygium glycoside is widely used in treating IgAN, but the high-level clinical evidence is absent.Objectives1. Reviewing the clinical and pathological features, and the initial therapeutic schedule of IgAN patients diagnosed by renal biopsy in Peking Union Medical College Hospital (PUMCH) between 2007-2014, and analyze the influence factors of initial therapy option.2. Analyzing the IgAN remission influence factors, especially the early treatment response, and assess the relationship between the disease remission-relapse status and renal prognosis.3. Comparing the difference of Tripterygium glycosides and glucocorticoids in patient selection and treatment efficacy, conduct a preliminary assessment the clinical value of Tripterygium glycoside.Methods1237 patients with biopsy proved IgAN from PUMCH between Jan.2007 and Dec.2014 were enrolled. Those with renal graft, other forms of nephropathy or with systemic diseases which might lead to secondary IgAN were excluded. The clinical and pathologicla data were collected for retrospective analysis of the clinical manifestations, pathological grading and the initial therapy options. The follow-up data was reviewed for analyzing the indicator change during follow-up and the prognosis.Results1.There were 1237 patients enrolled with a onset age of 36(29-45) years, mean arterial pressure (MAP) of onset 96.3±14.3 mmHg, estimated glomerular filtration rate (eGFR [CKD-EPI formula]) 83.1±34.5 ml/min/1.73m2,24h urinary protein (24hUP) 1.45 (0.69-3.09)g/d.27.4% patients have an obviously impaired kidney function and 44.5% patients had a pathological classification of Lee grading Ⅵ or Ⅴ.2. The total distribution of the initial therapy option:supportive therapy (27.3%), glucocorticoids monotherapy (33.3%), immunosuppressant agents monotherapy (10.0%) and combined therapy (30.3%). The major influence factors on initial treatment option were renal function, renal pathological grading and 24hUP. The age and metabolic factors such as obesity and diabetes might influence the use of glucocorticoids.3. The good initial treatment response (Scr or 24hUP) was associated with completed remission in IgAN (Scr:HR=1.42 [1.04-1.69], p=0.025;24hUP:HR=1.51 [1.18-1.93], p=0.001). IgAN had a high rate of recurrence, and the residual proteinuria might predict the IgAN relapse (HR=1.72[1.02-2.91], p=0.043)4. The consistent non-remission of IgAN (HR=6.10 [2.59-14.12], P<0.001) and relapse (HR=2.51 [1.14-4.42], p=0.023) could increase the risk of endpoint in IgAN patients.5. The median length of completed remission time shorter in Tripterygium glycosides than that in glucocorticoids, there was no significant difference in CR, relapse and renal prognosis between the Triptergium glycosides and glucocorticoids.Conclusions1.The ratio of IgAN in primary glomerular disieases decreased over time, while the clinical manifestations and pathological grading of IgAN worsened, which was considered being related with alteration of renal bopsy indications.2. The initial therapy option in PUMCH was mainly based on the clinical and pathological severity. RAS inhibitor was not fully used, while the immunosuppressant agents were on the contrary, and the ratio of combined immunosuppressant therapy was high. The age, metabolic factors and the year of renal biopsy also had obvious influence on the therapy options.3. The early decrease in Scr and 24hUP was related with clinical remission, which might be used for prediction of efficacy in early phase.4. The IgAN had a high recurrence rate, the age, initial proteinuria, residual proteinuria, and renal pathological grading were the four independent risk factors. The relapse and non-remission could significantly reduce the median renal survival length.5. The Tripterygium glycosides could induce 24UP remission in a shorter time compared with glucocorticoids The renal function was worse in the Tripterygium glycosides with a higher median age. but there was no significant difference on clinical remission, relapse and renal protection. |
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