| Background:Membranous nephropathy(MN)is an autoimmune disease with a group of glomerular basement membrane(GBM)epithelial cells immune complex deposition accompanied by diffuse thickening of GBM.According to the different causes of the disease,it is divided into idiopathic mbranous nephropathy(IMN)and secondary membranous nephropathy(SMN).Early diagnosis of IMN relied mainly on renal biopsy.The pathological feature was that in situ immune complexes formed by binding of certain pathogenic antigens to antibodies on podocytes were deposited under GBM epithelial cells with diffuse thickening and spike formation of GBM.Immunofluorescence showed that IgG,C3,and complement membrane attack complex C5b-9 showed diffuse fine-grained deposition along the outer side of the glomerular capillary wall.Under electron microscope,electron dense deposits and foot process fusion were observed in GBM epithelial cells.The pathogenesis of IMN is considered to be the binding of autoantibodies to the corresponding target antigens on podocytes,forming an in situ immune complex under the GBM epithelium,activating complement,triggering a series of chain reactions,ultimately leading to podocyte injury,GBM destruction,proteinuria produce.In recent years,autoantigens such as glomerular anti-M type phospholipase A2 receptor 1(M type Phohipase A2Receptor1,M type PLA2R1),podocyte membrane antigen type I thrombospondin type 7A domain(throbospondin typel domain-containing 7A,THSD7A)Related serum antibodies have been discovered one after another,and these new markers are important for the diagnosis of IMN.Early treatment of IMN was mainly glucocorticoids,and the remission rate was poor.With the wide application of immunosuppressants,Currently,it is recommended to treat with immunosuppressiveagents.However,there are still many controversies about specific treatment options,such as the choice of immunosuppressants and the specific dosage.These are still worthy of discussion.This article aims to investigate the deposition of PLA2R1 and IgG in renal tissue,and the combined effects of renal tissue PLA2R1 antigen and renal tissue IgG4 deposition on differential diagnosis of IMN and SMN;and comparison of different treatment regimens of cyclosporine,cyclosporine + hormone,simple hormone,cyclophosphamide + hormone in the treatment of IMN,and it is hoped to provide reference for the clinical diagnosis and treatment of IMN.Objective:1.To explore the relationship between PLA2R1 and IgG typing of renal tissue,and the combined effects of PLA2R1 antigen and renal tissue IgG4 deposition in renal tissue for differential diagnosis of IMN and SMN.2.To compare the efficacy of cyclosporin,cyclosporine + hormone,simple hormone,cyclophosphamide + hormone in the treatment of IMN by tracking 106 patients with IMN.Method:1.Retrospective analysis of 144 patients with membranous nephropathy who were admitted to the Department of Nephrology,First Hospital of Jilin University from December 2016 to June 2018,and confirmed by renal biopsy,including 101 males and 43 females.According to the cause,they were divided into IMN group and SMN group,including 136 cases in IMN group and 8 cases in SMN group(4 cases of systemic lupus erythematosus,3 cases of hepatitis B and 1 case of tumor).The renal tissue PLA2R1 and renal tissue were explored IgG typing deposition,and the combined effects of renal tissue PLA2R1 antigen and renal tissue IgG4 deposition for differential diagnosis of IMN and SMN.According to the pathological results,combined with the clinical data,the corresponding treatment plan was given,and the regular outpatient consultation was conducted.106 patients with IMN who hadcomplete medical records and were able to return to the clinic according to the rules of medical advice were selected,including 73 males and 33 females.According to the drug regimen,the patients were divided into 4 groups: cyclosporine group(6 cases),cyclosporine + hormone group(69 cases),simple hormone group(12 cases),cyclophosphamide + hormone group(19 cases).Retrospective analysis was used to track and compare treatment remission after 1,2,and 3 months of treatment in patients in different treatment groups.2.Clinical data and laboratory data of patients undergoing renal biopsy,including hospitalization number,name,gender,age,clinical diagnosis,blood lipids,plasma albumin,urea nitrogen,creatinine,24 h urine protein quantitation,surgical synthesis,pathology Results and laboratory indicators related to outpatient visits after discharge.3.All patients underwent renal biopsy.All specimens were examined by special staining such as HE,immunofluorescence and immunohistochemistry.Some cases were further examined by electron microscopy.Renal tissue IgG,IgM,IgA,C3,C4,C1 q and IgG subtypes were detected by direct immunofluorescence.The renal tissue PLA2R1 was detected by immunohistochemical staining and its expression was statistically analyzed.4.This study used Excel 2007 for data collation and statistical analysis by SPSS21.0.The patient's data were statistically described,and the measurement data were expressed in the form of mean ± standard deviation(),and the variance analysis between groups was used to test,and the normality test was performed by ShapiroWilk,and the normal distribution was adopted.The t test,non-compliance,uses a nonparametric rank sum test;the results of the count data are expressed as a rate(%),and the chi-square test or the Fisher exact probability test is used for comparison between groups;and for PLA2R1 expression and IgG4 deposition in renal tissue The combined effects of PLA2R1 expression and IgG4 deposition in renal tissue wereanalyzed by single factor and multivariate logistic regression.When P< 0.05,the difference was statistically significant.Results:1.Among the IgG subtypes,only IgG1 and IgG4 were significantly different between the IMN and SMN groups(IgG1(P=0.003),IgG4(P<0.001)).2.Through differential analysis of PLA2R1 expression,IgG4 deposition,renal tissue PLA2R1 expression and IgG4 deposition in renal tissue,univariate and multivariate logistic analysis,IgG4(P<0.001)and PLA2R1 expression(P<0.001)were used to differentially diagnose IMN.The difference was statistically significant with SMN.Combination of IgG4 deposition and PLA2R1 For differential diagnosis of IMN and SMN,only PLA2R1 was of interest(P = 0.001).3.In the single group of cyclosporine group and simple hormone group,there was no difference in the remission rate after 1,2,3 months of treatment(P>0.05);and after the treatment of cyclosporine + hormone group 1,2,3 months There was a difference in remission status(P<0.001).The comparison between the two groups showed that there were differences between the three groups,and the difference was statistically significant(P<0.05).The patients in the cyclophosphamide+hormone group were There was a difference in remission status at different times(P=0.023).After a pairwise comparison,there was a difference in the remission rate between 1month and 3 months(P=0.008),but 2 months and 3 months after treatment,2treatments and 1 months.There was no significant difference between month and month(P>0.05).4.The efficacy of each treatment group at 1,2,and 3 months of treatment showed that there was no significant difference in the efficacy of each treatment group at 1 month(P>0.05).At 2 months of treatment,the remission rate of each treatment group was 33.33%,52.17%,16.67%,36.84% in the cyclosporine group,cyclosporine + hormone group,simple hormone group and cyclophosphamide +hormone group.There were differences,and the difference was statistically significant(P=0.045).After pairwise comparison,the remission rate of patients with cyclosporine+hormone group was higher than that of simple hormone group,and the difference was statistically significant(P=0.012).The remission rate of each treatment group was 66.67%,72.46%,33.33%,and 68.42% at 3 months of treatment.There was a difference in the remission rate between the two groups(P=0.016).After a pairwise comparison,the remission rate of the cyclosporine + hormone group was higher than that of the cyclosporine group alone,and the difference was statistically significant(P=0.008).Conclusions:1.The IgG subtypes of IMN patients are mainly expressed by IgG4.2.Renal tissue PLA2R1 antigen and IgG4 subtype deposition is important for the diagnosis of IMN,the study of the combined effect of PLA2R1 antigen on the diagnosis of IMN is more significant.3.Through the treatment of the cyclosporine + hormone group,the cyclosporine+ hormone group,the simple hormone group,the cyclophosphamide + hormone group treatment group for 3 months,the cyclosporine + hormone group was the fastest,shortly The remission rate was the highest.After 3 months of treatment,the total remission rate of cyclophosphamide + hormone group was basically the same as that of cyclosporine + hormone group,which was significantly higher than that of simple hormone group and cyclosporine group. |
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