The Study Of Factors Affecting Remission,Recurrence And Prognosis In IgA Nephropathy

BackgroundIgA(immunoglobulin A nephropathy,IgAN nephropathy)is the most common primary glomerular nephritis worldwide,which is characterized by deposition of the IgA antibody in the glomerulus.The clinical recommends by KDIGO is mostly based on the lower-level clinical evidence.Because of lack of large-scaled randomized clinical trials,there is hardly any agreement on the IgAN therapy options so far.The factors affecting long-term prognosis of IgAN include many aspects,among which proteinuria is the most important.The relapse of proteinuria had significant correlation with renal outcome,but the research about the mechanism and related factors of relapse is still rarely reported.How to maintain the kidney function and whether different therapies have the same renal prognosis,these are still problems remain to be solved.Objectives1.To review the clinical data of IgAN patients followed-up regularly from 2007 to 2016 in Peking Union Medical College Hospital.To review the clinical and pathological patterns of IgA nephropathy.2.To analyze the complete remission of proteinuria in each therapy groups,and to investigate the factors affecting the renal prognosis.3.To study the CR group of IgAN,and to investigate the factors affecting the longe-term renal prognosis.MethodA total of 908 patients with biopsy proved IgAN from PUMCH between Jan 2007 and Mar 2016 were enrolled.Those with renal graft or combined with 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.714 cases which had achieved proteinurin CR goal were enrolled in the third part of research.The follow-up data has been reviewed for analyzing the rate of relapse during follow-up.Results1.Among 908 IgAN patients,the mean age is 36.9±10.8(18-69)years old,the mean arterial pressure(MAP)is 96±14mmHg,24h urinary protein(24hUP)is 2.19±2.43g/d,and the estimated glomerular filtration rate(eGFR)is 81±30.3Ml/min/1.73m2.2.The initial treatment options for IgAN patients in our hospital include supportive therapy(11%).corticosteroid(32%),immunosuppressant(29%)and glucocorticoid combined with immunosuppressant(28%).Among the patients who received RASi therapy alone,the overall performance of baseline 24hUP,baseline eGFR and other clinical indicators was less than that of the hormone and immunosuppressive therapy group.3.When compared with GCs,using RASi alone for initial treatment is less likely to achieve CR(HR=0.60,95%CI,0.41-0.87,p=0.01).eGFR 30-60ml/min/1.73m2 compared with the baseline eGFR>60 ml/min/1.73m2,24UP>1g/d at baseline was not conducive to the occurrence of CR.Age may affect the occurrence of CR.4.There is no significant correlation between each therapy group and the occurance of renal endpoint event;baseline 24hUP>lg/d was significantly related to recurrent or persistent proteinuria.CR is a risk factor for renal prognosis,time-averaged urinary protein(TA-UP)is an independent risk factors of the prognosis of kidney.5.RASi therapy group had a lower rate of relapse after CR.24hUP=1g.the baseline for the first time more than CR long June is a risk factor for recurrence of proteinuria;initial treatment of aged 40 or above is a protective factor for recurrence of proteinuria;6.There was no significant difference of the risk of renal endpoint between each therapy group.The eGFR level at CR had no significant correlation with renal outcome.Time-averaged urinary protein(TA-UP)is a strong predictor of renal outcome.The time taken from baseline to first CR>6 months is a risk factor of the reccurance of renal endpoint event.Conclusions1.The continued use of RASi alone does not increase the risk of recurrence and long-term adverse events in CR alone.2.For the patients who had achieved CR,baseline 24hUP no longer increase the risk of end point events.It is suggested that achieving proteinuria relief is an important goal of IgAN treatment.3.Higher the baseline proteinuria,longer the time required to reach the CR,and the increased risk of albuminuria recurrence after CR.Be careful when the patient spend a long period to reach CR.