| Research backgroundIgA nephropathy is a group of glomerulonephritis characterized by deposition of IgA in the mesangial area.Although the western medicine treatment of primary IgA nephropathy has made some progress,there are still many shortcomings.By contrast,combination of traditional Chinese and Western medicine has certain advantages in the treatment of IgA nephropathy.The clinical manifestations of primary IgA nephropathy are various and the prognosis is quite different.Therefore it is of great significance to accurately evaluate the condition and prognosis of patients with primary IgA nephropathy and intervene actively with appropriate treatment for improving long-term prognosis of the patients.In addition to clinical indicators,Modern medicine pays more attention to the patient's renal pathology when evaluating the prognosis of primary IgA nephropath.The pathological grading system of IgA nephropathy is constantly updated.The Oxford classification by the IgA Nephropathy International Collaboration in 2009 applied four pathological indicators that can independently affect the prognosis of the disease.They are mesangial hypercellularity,Endocapillary hypercellularity,segmental glomerulosclerosis and Tubular atrophy/interstitial fibrosis.The Oxford classification is receiving more and more attention,but whether it has a wide range of clinical applicability requires more rigorous clinical trials to verify.Whether the segmental glomerulosclerosis is related to the prognosis is controversial.The correlation between TCM syndromes and renal pathological factors is an important basis for the treatment of primary IgA nephropathy with integrated traditional Chinese medicine and Western medicine.At prestent,there are few studies on the clinical manifestation,renal Pathology and TCM Syndrome Characteristics of IgA Nephropathy with Segmental glomerulosclerosis.ObjectiveInitially explore the clinical traits,renal pathological features and the TCM syndromes differentiation in the patients of IgA nephropathy with segmental glomerulosclerosis.MethodologyThis study adopts a single-center retrospective approach,collecting the clinical,pathological and four diagnostic data of primary IgA nephropathy confirmed by renal biopsy from January 2013 to October 2018 in the Department of Nephrology,Guang'anmen Hospital,Chinese Academy of Traditional Chinese Medicine.The patients are divided into two groups,the one with segmental glomerulosclerosis and the other without segmental glomerulosclerosis.The purpose of this study is to explore the differences in clinical manifestations,renal pathological characteristics and TCM syndromes between the two groups of IgA nephropathy patients.Result1 General situation1.1 IncorporationA total of 218 patients with IgA nephropathy were included in the study.There were 119 patients with segmental glomerulosclerosis,accounting for 54.6%of all patients and 99 patients without segmental glomerulosclerosis,accounting for 45.4%of all patients.1.2 GenderThe proportion of males accounted for 61.3%and the females accounted for 38.7%in the group with segmental glomerulosclerosis.Meanwhile,the proportion of males accounted for 54.5%and the females accounted for 45.5%in the group without segmental glomerulosclerosis.The male patients were more common in both groups.The difference between the two groups was not statistically significant(P>0.05).1.3 Age of renal biopsyThe average age of patients undergoing renal biopsy in this study was 39.61±12.39 years old.The average age was 38.75±11.75 years old in the group with segmental glomerulosclerosis and The average age was 40.65±13.09 years old in the group without segmental glomerulosclerosis.The difference between the two groups was not statistically significant(P>0.05).1.4 Disease courseThe median(quartile)duration of IgA nephropathy was 12(2.0,48.0)months in this study.The median(quartile)duration of IgA nephropathy in the group with segmental glomerulosclerosis was 12(2.0,48.0)months.The median(quartile)duration of IgA nephropathy in the group without segmental glomerulosclerosis was 12(1.5,48)months.The difference between the two groups was not statistically significant(P>0.05).1.5 Body mass index1.6 The BMI of IgA nephropathy was 24.83±4.08kg/m2 in this study.The BMI was 24.65±4.16kg/m2 in the group with segmental glomerulosclerosis.The BMI was 25.05±3.99kg/m2 in the group without segmental glomerulosclerosis.The difference between the two groups was not statistically significant(P>0.05).1.7 Predisposing factorIn this study,75.7%of the patients had no obvious predisposition.Meanwhile infection is the most common cause of onset in patients with predisposing factors.Respiratory tract infection was the main cause of infection in both groups.The difference between the two groups was not statistically significant(P>0.05).2 Clinical indicators2.1 First clinical symptomThe most common first clinical symptom in this study were fatigue(24.3%)and edema(23.6%).The difference between the two groups was not statistically significant(P>0.05).2.2 Hypertension grading74.31%of patients in this study found a history of hypertension.The proportion of patients suffering hypertension was 73.1%in the group with segmental glomerulosclerosis.72.7%of patients suffered hypertension in the group without segmental glomerulosclerosis.The difference between the two groups was not statistically significant(P>0.05).2.3 24-hour urine protein quantitationThe median level of 24-UTP in this study was 1.66(0.87,2.85)g/24h.The median level of 24-UTP in the group with segmental glomerulosclerosis was 1.83(1,3.03)g/24h.The median level of 24-UTP in the group without segmental glomerulosclerosis was 1.45(0.65,2.41)g/24h.The difference between the two groups was not statistically significant(P>0.05).2.4 Renal functionIn this study,the indicators of renal function in the group with segmental glomerulosclerosis were Scr 102.0(81.0,156.0)umol/L,BUN 6.5(4.54,8.60).mmol/L,UA 415(330,482)umol/L and eGFR 67.7±32.11 ml/(min-1.73m2).The indicators of renal function in the group without segmental glomerulosclerosis were Scr 94.0(69.0,137.0)umol/L,BUN 5.56(4.70,7.80)mmol/L,UA 401(319,476)umol/L and eGFR 75.80±34.52 ml/(min·1.73 m2).The median level of BUN was higher in the group with segmental glomerulosclerosis than in the group without segmental glomerulosclerosis,and the difference between the two groups was statistically significant(P<0.05).There was no statistically significant difference in the Scr,UA,eGFR and CKD staging between the two groups(P>0.05).2.5 Serum albuminThe median level of ALB in the group with segmental glomerulosclerosis was 39.10(34.30,42.0)g/L.The median level of ALB in the group without segmental glomerulosclerosis was 39.0(33.5,44.6)g/L.The difference between the two groups was not statistically significant(P>0.05).2.6 Blood lipid profileIn this study,the indexes of blood lipid levels in the group with segmental glomerulosclerosis were TCHO 4.86(4.16,5.85)mmol/L,TG 1.72(1.17,2.80)mmol/L,and HDL-C 1.11(0.96,1.32)mmol./L,and LDL-C 2.99(2.53,3.65)mmol/L.The indexes of blood lipid levels in the group without segmental glomerulosclerosis were TCHO 4.54(4.08,5.39)mmol/L,TG 1.76(1.26,2.58)mmol/L,HDL-C 1.15(0.95,1.39)mmol/L,and LDL-C 2.86(2.31,3.47)mmol/L.The difference between the two groups was not statistically significant(P>0.05).2.7 Other indicatorsIn this study,other indicators in the group with segmental glomerulosclerosis were HCO3-24.1(22.4,25.8)mmol/L,HGB 137.0(123.0,154.0)g/L,IgA 2.86(2.09,3.58)g/L,C3 0.99(0.80,1.19)g/L,IgA/C3 3.12(2.18,3.80).Other indicators in the group without segmental glomerulosclerosis were HCO3-23,90(22.50,26.30),HGB 137.0(120.0,151.0)g/L,IgA 3.10(2.42,3.96)g/L,C3 0.95(0.81,1.09)g/L,IgA/C3 3.24(2.43,4.55).The difference between the two groups was not statistically significant(P>0.05).3 Renal pathological observation index3.1 Immunofluorescence depositionsIn this study,the types of immune concomitant in the group with segmental glomerulosclerosis proportionally high to low were IgA+IgM+C3 60(51.7%),IgA+C3 36(31.0%),IgA+IgM+IgG+C3 10(8.6%),IgA+IgM 4(3.4%),IgA 3(2.6%),IgA+IgG 2(1.7%),IgA+IgG+C3 1(0.9%).The types of immune concomitant in the group without segmental glomerulosclerosis proportionally high to low were IgA+IgM+C3 54(55.1%),IgA+C3 32(32.7%),IgA+IgM+IgG+C3 6(6.1%),IgA 3(3.1%),IgA+IgM 2(2.0%),IgA+IgG 0(0.0%).The difference between the two groups was not statistically significant(P>0.05).3.2 Oxford pathology classificationIn this study,the incidence of Oxford classification pathological indicators in the group with segmental glomerulosclerosis was M1 83.2%,E1 31.9%,T1 51.7%,T2 21%,C1 51.3%,and C2 11.8%.The incidence of Oxford classification pathological indicators in the group without segmental glomerulosclerosis was M179.8%,El 19.2%,T1 35.4%,T2 7.1%Cl 28.3%,C2 9.1%.There was no statistically significant difference in mesangial hypercellularity between the two groups(P>0.05).The incidence of endocapillary hypercellularity was higher in the group with segmental glomerulosclerosis than in the group without segmental glomerulosclerosis,there was a statistically significant difference between the two groups(P<0.05).The incidence of tubular atrophy/interstitial fibrosis and cellular or fibrocellular crescent was higher in the group with segmental glomerulosclerosis than in the group without segmental glomerulosclerosis,there was a statistically significant difference between the two groups(P<0.01).4.TCM syndrome data4.1 TCM symptomsIn this study,29 clinical symptoms of TCM were collected.The most common five clinical symptoms of TCM were fatigue(62.4%),edema(30.3%),foaming urine(18.8%),cough(17.4%)and spontaneous sweating(11.9%).4.2 Main syndrome type of TCMAccording to the dialectical process of "IgAN Western Medicine Diagnosis and Practice Guidelines for TCM Syndrome Differentiation",this study firstly identified the disease stage:12.3%of patients in acute attack and 87.7%of patients with chronic duration.Secondly,identify the main type of each period.The main syndrome types associated with the group with segmental glomerulosclerosis were arranged in proportion from high to low.They were fei and pi qi deficiency syndrome(50.4%),qi and yin deficiency syndrome(16.8%),gan and shen yin deficiency syndrome(16.0%),pi and shen yang deficiency syndrome(8.4%),xiajiao shire syndrome(5.0%)and waigan fengre syndrome(3.4%).The main syndrome types associated with the group without segmental glomerulosclerosis were arranged in proportion from high to low.They were fei and pi qi deficiency syndrome(37.4%),Qi yin deficiency syndrome(25.3%),waigan fengre syndrome(15.2%),gan and shen yin deficiency syndrome(11.1%),pi and shen yang deficiency syndrome(9.1%),xiajiao shire syndrome(2.0%).The incidence of waigan fengre syndrome was higher in the group with segmental glomerulosclerosis than in the group without segmental glomerulosclerosis.There was a statistically significant difference between the two groups(P<0.05).There was no statistical significant difference in other main syndrome types of TCM(P>0.05).4.3 TCM minor syndromeIn this study,Shire syndrome and xueyu syndrome are most common in both groups.But there was no significant difference between the two groups(P>0.05).Conclusion1 In the group with segmental glomerulosclerosis,24-hour urine total protein and blood urea nitrogen levels were higher,meanwhile the incidence of tubular atrophy/interstitial fibrosis and cellular or fibrocellular crescentwere were higher.From the clinical and pathological characteristics analysis,indirect confirmation of segmental glomerulosclerosis may be one of the risk factors affecting the prognosis of IgA nephropathy.2 The clinical symptoms are more common in fatigue and edema.The main syndrome of traditional Chinese medicine is mainly based on fei and pi qi deficiency syndrome and the TCM minor syndrome is more common with shire and xueyu syndrome. |
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