Prognosis And Clinicopathological Features Of Idiopathic Membranous Nephropathy

Background and objectivesMembranous nephropathy is the most common pathological type of NS whichis divided into idiopathic and secondary. The reason of idiopathic membranousnephropathy is a kind of membranous nephropathy which eliminates some secondaryfactors such as tumour, hepatitis B and diabetes, besides, its aetiological agent is notclear. It is reported by epidemic disease researchers that IMN takes9.9%-13.5%ofall primary glomerular disease. It mainly occurred in the elderly between age of40-50, and the rate of males and females, the adults and children is respectively2:1,26:1, but recently the morbidity of IMN is on rise year by year with a youngertrend. The clinical manifestation of IMN is various, and the represented one is thelarge amount of blood in the urine protein. Some studies in the past believed thatlower urinary protein can make the female self-remission easier, but higher urinaryprotein, its sustained non-remission, interstitial fibrosis and tubular atrophy aredanger factors correlating with prognosis. Studies in Europe and America indicatethat the situation of IMN patients’ prognosis is not well, but it is opposite in the Asia.Certainly whether the above factors correlating with prognosis fit for the Chinese ornot needs to research with a deep.It is based on above studies and the existed controversies, the thesis did anobvious research for a number of IMN patients so as to discuss the correlatingdangerous factors with prognosis of IMN patients.Participants and methodsThe study was applied to patients with age of14even older who werediagnosed with glomerular membranous nephropathy with more than10glomerulusby operating biopsy puncture in First Affiliated Hospital of Sun Yet-sen Universityduring2004.01.01to2011.12.31. This study excluded patients who had thesecondary glomerular disease, systemic lupus erythenlatosus nephritis, amyloidosisnephropathy, diabetic nephropathy，tumor-associated nephropathy, detection of HBV-related glomerulonephritis, transplant kidney disease, associated with ESRDonset(eGFR<15ml/min1.73m2, dialysis, kidney transplant) or the patients’ follow-uptime was less than12months. The main end-point of the research include: Scr goesup more than50%,reach to ESRD(EGFR<15ml/min1.73m2, dialysis, kidneytransplant), death.The minor end-point include:1.CR:urine protein quantitation is less than0.3g/24hr, the normal range ofplasma albumin, stable renal allograft recipient.2.PR: the urine protein goes down50%than the normal, plasma albumin ismore than30g/L and the renal allograft recipient is stable.3.Spontaneous remission: the patients who aren’t use hormone orimmunosuppressor can reach to complete or part remission.Statistical analysisQualitative data comparison between two groups by chi-square test or Fisher’sexact probability calculation method or Wicoxon rank and inspection. Moreover,qualitative data is expressed by frequency and quantitative data between two groupsby using t test or Wicoxon rank and inspection. Standard normal distribution ofquantitative data is expressed by mean and deviation, non-standard normaldistribution of quantitative data is expressed by a median. Survival analysis using thelife table method、kaplan-Meier curve and Log-Rank inspection. The exploration ofcorrelating dangerous factors are expressed by the Cox proportional hazardsregression model. By Using spss13.0statistic software to analyse, and thephenomenon of two sides’ p are less than0.05is defined as statistic difference.Results（1）there are608patients with age of14even older who were diagnosed withglomerular membranous nephropathy by operating biopsy puncture during2004.01.01to2011.12.31. In accordance with exclusive standard,419patients fittedfor this study and306patients putted into analysis after follow-up time, whichincluded189patients whose urine protein were less than3.5g per24hours with61.7%,53patients whose urine protein were more than3.5g but less than6g per24 hours with17.3%and64patients whose urine protein were more than6g per24hours with20.9%.（2）With a median follow-up of27months (range12~113months),195(63.7%)patients were partly relieved,140(45.8%)patients were complete remission,55（17.9%）patients were partial remission,71(23.2%) patients were Spontaneousremission,23(7.5%) patients were dead and15(5.1%) patients reached the endnephropathy with10patients reached to ESRD and5patients’ Scr gone up morethan50%.（3）15patients in the reached the end nephropathy include8patients inA(4.2%),4patients in B(7.5%) and3patients in C(4.6%). The A survival rate forlong-term of patients with kidney is superior to C（Log Rank=9.032，P=0.011）. Thecharging proportion of glomerulosclerosis classification in the renal biopsypathology(per1，HR=3.38，95%CI1.32~8.65，P=0.011) are dangerous factors whichaffect the reached the end nephropathy.23dead patients include10in A(the rate is5.3%),5patients in B(the rate is9.4%) and8patients in C(the rate is12.5%). The Asurvival rate for a long time of patients with kidney is superior to C （LogRank=7.569，P=0.023）.The independent dangerous factors affected dead include theage of growth during renal biopsy(per10y，HR=2.13，95%CI1.34~3.78，P=0.001)and the concentration of Scr goes up(per100mmol/L，HR=2.92，95%CI1.52~5.61，P=0.001) during renal biopsy. However, the concentration of ALB during renalbiopsy(per10g/L，HR=0.24，95%CI0.09~0.64，P=0.005) and the treatment with theuse of hormone combined with immunosupressor during follow-time（HR=0.17，95%CI0.03~0.95，P=0.043）are protect factors of dead.（4） A group has123members in195reliveved patients(65.1%),B group has21(58.5%),C group has41(64.1%). The respectively rate of71patients who cameabout Spontaneous remission in A,B,C group is49（25.9%）、11（20.8%）、11（17.2%）.（5）Proportion of glomerular sclerosis ball/Segmental sclerosis and TIL scorewere positively correlated（r=0.527，P<0.001）. Serum creatinine and blood ureanitrogen as glomerulosclerosis grading and classification levels rise with TIL. The higher the level of glomerular sclerosis may prompt grading and classification TILworse renal prognosis.Conclusions（1）the IMN patients with non-nephritic syndrome whose patients’ survivalrate for a long time and the survival rate of renal are exceed the IMN patients whoseurine protein level with nephritic syndrome.（2）The clinical protect factors affected the survival rate of IMN patientsinclude the concentration of ALB during renal biopsy and the use of hormonecombined with immunosupressor during follow-up time. However, the clinicaldangerous factors affected the survival rate of IMN patients include the age ofgrowth during renal biopsy and the concentration of Scr goes up during renal biopsy.Besides, the dangerous factor of renal pathology is the glomerular pathologygrading.（3） the IMN patients whose urine protein level higher，glomerulosclerosishigher grade levels and higher TIL grade level are higher should monitor renalfunction and urine protein. In addition, doctors should assess patients as early aspossible, then perform proper treatment method.