TCM Syndrome, Clinical Pathology And Prognosis Analysis Of Capillary Endothelial Cell Proliferative IgA Nephropathy

Research backgroundIgAN nephropathy(IgAN)refers to the pathological manifestations of glomerular mesangial IgA deposition-based glomerulonephritis,is the world's most common primary glomerular disease.It has complex pathogenesis,with a wide range of clinical manifestations and diverse pathologies,and there is no effective treatment.It is alsothe crucial cause of end-stage renal disease(ESRD).Therefore,early diagnosis,accurate assessment of prognosis and active treatment are very important to control the progress of IgAN.The Oxford classification of IgA nephropathy,as an important means of IgAN assessment of pathological manifestations,developed the mesangial cell proliferation(M),capillary endothelial cell proliferation(E),glomerular segmental sclerosis(S)and tubular atrophy or interstitial fibrosis(T)as the pathological indexes to evaluate the prognosis of IgAN.Among them,the capillaryendothelial cell proliferation(E)for IgAN patients with clinical and prognostic value is still controversial.Because of its low number of clinical cases,susceptible to drugs,infections and other factors,and often associated with varying degrees of various diseases such as the status quo,have led to the study of endothelial proliferative IgAN stillhasn't been conclusive.Traditional Chinese medicine(TCM)on IgA nephropathy has a more complete understandingsystem,and can link their renal pathology,from the macro and micro perspective,respectively,diagnosis and treatment.However,limited to the Oxford classification of IgA nephropathy has not used widely,TCM still needs much more practice to understand perfectly with the endothelial hyperplasia(E)lesions.Thus,this study intends to explore the distribution of TCM syndromes,clinicopathological features and TCM-WM treatment rules,to analyze the prognosis of those patients,and to further evaluate the significance and value of endothelial proliferation(E)in the clinical practice,to enrich the understanding of Oxford pathological classification system by TCM,in order to provide a basis for diagnosis and treatment of Chinese and Western medicine.Purposes1.Initially explore the TCM syndromes and clinicopathological features of capillary endothelial cell proliferative IgA nephropathy.2.Initially explore the prognosis of capillary endothelial cell proliferative IgA nephropathy.MethodsBased on the Chinese medicine dialectical guidelines and the Chinese Academy of Traditional Chinese Medicine Guanganmen Hospital Department of nephrology dominant disease diagnosis and treatment programs of IgAN,selected from December 2003 to January 2017 in our department by renal biopsy diagnosed as IgAN were 407 cases,retrospective analysis 78 cases of capillary endothelial cell proliferative IgAN were included in the study.The distribution of TCM syndromes,clinical and pathological features were observed.46 cases were followed up for more than 6 months and the clinical data were included in the follow-up study to further analyze the treatment of endometrial hyperplasia IgAN and prognosis.Results1 TCM syndrome1.1 SymptomsCommon symptoms were fatigue(58.9%),low back pain(53.8%)and pharyngeal discomfort(including sore throat,throat and sore throat,48.7%).1.2 TCM type distributionCombined with our department and guidelines in the IgAN TCM syndrome differentiation,the 78 patients in this study were divided into four types.According to the statistics:(1)There were 39 cases(50.0%)in Wei is not solid,wind heat and dampness within theinjury kidney type.(2)Liver and kidney deficiency,Yin Huo-wang-type a total of 16 cases(20.5%);(3)There were 17 cases(21.8%)of Spleen and kidney qi deficiency,dampness stagnation type.(4)Weakness of spleen and stomach typea total of 6 cases(7.7%).Among them,Wei is not solid,wind heat and dampness within the injury kidney type is the main type of endothelial hyperplasia IgAN(P<0.05).1.3 Correlation between TCM syndrome and clinical1.3.1 General situationComparison of four TCM syndromes and the incidence of sex,age of onset and whether the relationship between precursor infection There was no difference between different genders(P>0.05).At the age of onset,Wei is not solid,wind heat and dampness within the injury kidney type has an earlier age than that of the Liver and kidney deficiency,Yin Huo-wang-type(P<0.05).In the case of prodrug infection there were more common predisposing cases inWei is not solid,wind heat and dampness within the injury kidney type than those of other syndromes(P<0.05).1.3.2 Laboratory indicatorsThe correlation between the four TCM syndromes and the 24h-UTP,eGFR,Cr,CKD staging and RBC-M values were compared.Weakness of spleen and stomach type had a muchhigher RBC-M value than liver and kidney deficiency,Yin Huo-wang-type andSpleen and kidney qi deficiency,dampness stagnation type(P<0.05).There was no significant difference between the four TCM syndromes in 24h-UTP,eGFR,Cr distribution and CKD staging(P>0.05).1.4 Correlation between TCM syndrome and pathological featuresThere was no statistically significant result in the TCM syndromes of patients with endothelial hyperplasia IgAN and the grades of Oxford pathology,the main typing,and the correlation between spheroid sclerosis and crescents(P>0.05).2 Clinical and pathological features2.1 Clinical features2.1.1 General situationThe incidence of endometrial hyperplasia IgAN was 19.2%,and the sex ratio was 1.23:1(P>0.05).The mean age of onset of IgAN was 34.86±13.31 years old.Thirty patients(38.5%)had a prodromal infection.A total of 16 patients(20.5%)developed macroscopic hematuria.2.1.2 Laboratory indicatorsThe baseline levels of laboratory markers were observed in 78 patients with endothelium proliferative IgAN.(1)The average 24h-UTP was 2.568±2.043 g/d,of which 61 cases(78.2%)24h-UTP>1g/d,and 1-3.5g/d were more(P<0.05);(2)The mean Cr was 129.70 ± 93.85?mol/L,and the baseline Cr was increased in 38 cases(48.7%).The average eGFR was 69.75±33.12 ml/min(1.77m2),19 cases were CKD1-524.4%),27 cases(34.6%),23 cases(29.5%),6 cases(7.7%)and 3 cases(3.8%);(3)There were 50 patients(64.1%)with hypertension,especially those with hypertension level 3(P<0.05).(4)There were 65 cases(83.3%)with microscopic hematuria and the average RBC-M was 60.41±141.11/HP;(5)Other laboratory indicators:19 cases(24.4%)with elevated urea nitrogen;26 cases(33.3%)with elevated uric acid;35 cases(44.9%)with albumin decreased;There were 18 cases(23.1%),38 cases(48.7%)and 37 cases(47.4%)of cholesterol,triglyceride and low density lipoprotein,respectively.There were 14cases(17.9%)with hemoglobin decrease.Data analysis,endothelial hyperplasia of IgAN nephropathy in patients with poor renal function,clinical often showed more proteinuria(>1g/d)andhypertension.2.2 Pathological features2.2.1 Immunofluorescence depositionsIn addition to IgA and C3,there were 48 cases(61.5%)with IgM deposition,8 cases(10.3%)of FRA deposition,7 cases(8.9%)of IgG deposition,6 cases(7.6%),ALB deposition in 1 case(1.3%).2.2.2 Oxford pathologic type75 cases(96.2%),47 cases(60.3%)and 52 cases(66.7%)/20 cases(25.6%)with M1,S1 and T1/2 lesions,respectively.2.3 Correlation between clinical and pathological featuresComparison of the degree of M,S,T and the main clinical prognostic indicators(24h-UTP,HT and eGFR)correlation between the degree of M lesions in 24h-UTP,HT and eGFR were no significant difference(P>0.05);The extent of T lesions was associated with decreased eGFR and severe hypertension(P<0.05);The severity of S was associated with a higher severity of hypertension(P<0.05).There was no statistical difference(P>0.05).3 Treatment outcomes3.1 Chinese and Western medicine treatment78 cases were treated with integrated traditional Chinese and Western medicine in a total of 69 cases,with a total of 9 cases treated with traditional Chinese medicine alone.3.1.1 Syndrome differentiationWei is not solid,wind heat and dampness within the injury kidney type to Yiqi Qingre Decoction(39 cases,50%);Liver and kidney deficiency,Yin Huo-wang-type to zhibaidihuangwan and two to pill(16 cases,20.5%);Spleen and kidney qi deficiency,dampness stagnation typewith Dangguishaoyaosan fangjihuangqi Decoction add and subtract(17 cases,21.8%);Weakness of spleen and stomach type given SHENLINGBAISHU or Banxiaxiexin Tang(6 cases,7.7%).Astragalus,Atractylodes,Poria,plantain,Oldenlandia for high frequency therapy based endothelial proliferative IgAN(drug use frequency of total prescriptions,2/3)3.1.2 Western medicine treatment programThe use of RAS blockers in the treatment of 40 cases(57.9%);Immunosuppressant(Includes glucocorticoid,cyclophosphamide,azathioprine,mycophenolate mofetil and cyclosporin A)treatment in 36 cases(52.2%)3.2 PrognosisA total of 45 patients were included in the follow-up study.The mean follow-up time was from 45.9±34.9 months,and the ratio of male to female was 1.5:1.Total effective rate:82.2%(37 cases).3.2.1 Comparison of before and after treatment(1)Laboratory index:24h-UTP and RBC-M significantly reduced(P<0.001),the level of ALB increased significantly(P<0.05).But eGFR,Cr,BUN and HGB levels showed no significant difference(P>0.05).(2)Immunosuppressive agents:Comparison of 20 cases(44.4%)with immunosuppressive agents and 25 cases(55.6%)without those agents before and after treatment on clinical indicators of difference.The 24h-UTP,eGFR and RBC-M were found significantly relieved(P<0.05),the latter is only RBC-M value difference was statistically significant(P<0.05).3.2.2 End eventIn this study,a total of 5 patients(1 patient eGFR decreased and<15ml/min 1.73m2;the remaining 4 patients entered the long-term regular renal replacement therapy),the average time was 45.9±34.9 months;accounting for the total number of the study was 11.1%.ConclusionsThe main TCM syndromes of capillary endothelial cell proliferative IgAN are Wei is not solid,wind heat and dampness within the injury kidney type,while early renal function damage,more proteinuria(>1g/d)and hypertension as the main clinical manifestations.Its pathological features always show Immunofluorescence deposition to IgA,C3 and IgM-based,with Oxford type often can be combined M1,S1 and T1 lesions.Due to the small number of cases,the correlation between capillary endothelial cell proliferation and IgAN prognosis is still unclear.