扁桃体切除术治疗IgA肾病的疗效评价:一项meta分析

doi:10.3969/j.issn.1004-583X.2024.03.001

摘要/Abstract

摘要：

目的扁桃体切除术治疗IgA肾病(IgAN)的疗效目前仍存在争议,这项meta分析旨在评价其作为辅助或独立治疗的疗效,为其在临床中的应用提供更充分的循证学依据。方法计算机检索建库至2022年11月1日在Pubmed、Embase、ScienceDirect、Cochrane library、Web of Science、中国知网(CNKI)、维普网(VIP)、中国生物医学文献数据库(CBM)和万方数据库公开发表的关于扁桃体切除术治疗IgAN的文献,以蛋白尿、血尿、完全缓解率及终末期肾病(ESRD)发生率作为观察点,使用Stata 12.0软件进行统计学分析。结果共纳入36篇文献,涉及5797名原发性IgAN患者。Meta分析结果显示,扁桃体切除术作为辅助或独立治疗手段与单纯药物治疗相比,蛋白尿缓解率显著增加(OR=4.44,95%CI: 3.14~6.27),血尿缓解率显著增加(OR=5.11,95%CI: 2.92~8.93),完全缓解率显著增加(OR=3.32,95%CI: 2.79~3.96),而ESRD发生率显著降低(OR=0.24,95%CI: 0.17~0.33)。结论扁桃体切除术作为辅助或独立治疗手段,有助于诱导临床缓解并抑制终末期肾病的进展,临床上应更加重视其应用价值。

关键词: 肾小球肾炎, IGA, 扁桃体切除术, 临床缓解, 终末期肾病, Meta分析

Abstract:

Objective The efficacy of tonsillectomy in immunoglobulin A nephropathy (IgAN) still remains controversial. This meta-analysis aims to evaluate the efficacy of tonsillectomy as an auxiliary or independent therapy and provide more evidence-based evidence for its clinical application. Methods We retrieved the literatures about the efficacy of tonsillectomy in IgAN published in Pubmed, Embase, ScienceDirect, Cochrane library, Web of science, Chinese National Knowledge Infrastructure (CNKI), VIP, China Biomedical Literature Database (CBM) and Wanfang databases from the time of establishment to November 1, 2022. The rate of proteinuria remission, hematuria remission, complete remission (CR) and end-stage renal disease (ESRD) were taken as observation points and meta-analyse were conducted by using Stata 12.0 software. Results A total of 36 studies representing 5797 patients with primary IgAN were ultimately enrolled. Meta-analysis showed that compared with drug therapy alone, tonsillectomy, as auxiliary or independent therapy, significantly improved proteinuria remission rate (OR=4.44, 95%CI: 3.14-6.27), hematuria remission rate (OR=5.11, 95%CI: 2.92-8.93) and CR rate (OR=3.32, 95%CI: 2.79-3.96), and significantly reduced incidence of ESRD (OR=0.24,95%CI: 0.17-0.33). Conclusion As auxiliary or independent treatment, tonsillectomy may induce clinical remission and inhibit the progression of ESRD in patients with IgAN and more attention should be paid to its application value in clinic.

Key words: glomerulonephritis, IGA, tonsillectomy, clinical remission, end-stage renal disease, Meta-analysis

中图分类号:

R692.31

孙帅刚, 翟亚玲, 张文惠, 田慧娟. 扁桃体切除术治疗IgA肾病的疗效评价:一项meta分析[J]. 临床荟萃, 2024, 39(3): 197-207.

Sun Shuaigang, Zhai Yaling, Zhang Wenhui, Tian Huijuan. Tonsillectomy as a therapy for patients with IgA nephropathy: A meta-analysis[J]. Clinical Focus, 2024, 39(3): 197-207.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2024.03.001

https://huicui.hebmu.edu.cn/CN/Y2024/V39/I3/197

图/表 10

参考文献 49

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作者(年份)	国家/ 地区	研究类型	患者数量 (T/NT)	年龄 (岁)	性别 (男/女)	治疗方式		观察结局
作者(年份)	国家/ 地区	研究类型	患者数量 (T/NT)	年龄 (岁)	性别 (男/女)	干预组	对照组	随访时间 (年)	尿蛋白缓解	尿红细胞缓解	完全缓解	ESRD	NOS
冯凤仪(2006)^[12]	中国	PC	32/34	7.4	40/26	T+S	S	0.5	-		22/12		7
黄远航(2009)^[13]	中国	R	109/98	30.7	114/93	T+S	S	1.0	-		89/50		7
江枫(2008)^[14]	中国	PC	35/40	-	38/37	T	S	0.5	-		16/13	2/8	7
刘虹(2009)^[15]	中国	CC	57/51	32.0	56/52	T+S	S	1.0	-		47/22		7
孟骏(2012)^[16]	中国	PC	24/18	31.6	16/26	T+S	S	1.0	19/8	18/3	15/3		7
田滨瑶(2022)^[17]	中国	R	34/49	32.7	42/41	T/T+S/T+I/T+S+I	S/I/S+I/保守治疗	3.9	-		17/17		7
吴和燕(2020)^[18]	中国	R	40/80	14.3	70/50	T+S	S	8.1	-		29/36	2/4	8
肖爱华(2007)^[19]	中国	PC	12/15	21.4	17/10	T	S	0.5	-		10/2		7
于二峰(2019)^[20]	中国	PC	59/31	30.3	34/56	T+S	S	3.0	47/13	49/9			7
俞雨生(1991)^[21]	中国	PC	41/39	25.4	59/21	T	S	1.5	-		19/9		7
Akagi(2004)^[22]	日本	RCC	41/30	31.1	32/39	T+S	S	13.0	-		10/4	2/8	8
Chen(2007)^[23]	中国	RCC	54/58	27.3	66/46	T+S	S	10.8	-		25/16	2/7	8
Feehally(2016)^[24]	意大利	MRCS	41/41	35.5	42/40	T+S	S	3.3	-			3/8	7
Hirano(2019)^[25]	日本	MRCS	252/813	35.0	535/530	T+无S/S/SP	无S/S/SP	5.8	-			11/118	8
Hoshino(2016)^[26]	日本	MCS	209/918	44.1	638/489	T+SP	SP/S/保守治疗	8.3	-			7/146	8
Hoshino(2017)^[27]	日本	RCS	26/26	32.6	18/34	T+SP	S	6.0	-		15/5		8
Hotta(2001)^[28]	日本	RCS	191/34	34.4	-	T+S/SP	S/SP	6.9	-		114/12		8
Hotta(1993)^[29]	日本	PC	26/19	30.2	17/28	T+SP	SP	3.0	14/5	20/8			7
Katafuchi(2016)^[30]	日本	RCT	26/33	39.2	27/32	T+S	S	4.8	16/13	18/20	12/9		-
Kawaguchi(2010)^[31]	日本	RCS	307/81	34.3	177/211	T+S or T	S	5.0	-		197/19		8
Kawamura(2014)^[32]	日本	MRCT	33/39	38.2	35/37	T+S	S	1.0	20/14	22/23	15/10		-
Kawasaki(2006)^[33]	日本	PC	16/16	12.2	17/15	T+SP	S	2.0	-		12/9		7
Komatsu(2008)^[34]	日本	PNC	35/20	34.5	21/34	T+S	S	4.5	23/7	27/9	19/5	0/1	7
Komatsu(2016)^[35]	日本	MRCS	46/33	34.9	31/48	T+S	S or保守治疗	4.7	37/15	38/18	33/14	0/1	7
Maeda(2012)^[36]	日本	RCS	70/130	31.7	67/133	T+S/SP	S+SP	5.2	-		24/12		8
Matsumoto(2018)^[37]	日本	RCS	87/87	31.0	68/106	T+S/SP	S+SP	7.8	-			6/22	8
Miyamoto(2016)^[38]	日本	MRCS	161/123	37.3	123/161	T+S	S or保守治疗	4.1	-		92/49		7
Miyazaki(2007)^[39]	日本	MPCS	78/23	34.4	43/58	T or T+S	S or保守治疗	5.0	-		52/10		8
Nishi(2004)^[40]	日本	R	46/74	32.6	69/51	T+S	S	16.4	-			5/19	8
Ochi(2013)^[41]	日本	RCS	26/15	31.1	15/26	T+S	S	1.0	20/8	23/5	18/2		7
Ogura(2021)^[42]	日本	RCS	32/80	32.0	49/63	T+S	S or保守治疗	5.0	26/37	26/37	24/31	0/0	8
Ohya(2013)^[43]	日本	RCS	41/21	34.6	20/42	T+S	S	5.8	-		24/10		8
Rasche(1999)^[44]	日本	RCS	16/39	29.0	38/17	T+S	S	3.4	-			10/14	7
Sato(2003)^[45]	日本	RCS	30/40	46.5	51/19	T+S	S or保守治疗	5.9	-			4/25	8
Xie(2003)^[46]	日本	RCS	48/70	32.3	64/54	T+S	S	16.1	-			5/18	8
Yang(2016)^[47]	中国	RCT	49/49	30.0	45/53	T+S	S	4.0	47/25	45/23			-

作者(年份)	国家/ 地区	研究类型	患者数量 (T/NT)	年龄 (岁)	性别 (男/女)	治疗方式		观察结局
作者(年份)	国家/ 地区	研究类型	患者数量 (T/NT)	年龄 (岁)	性别 (男/女)	干预组	对照组	随访时间 (年)	尿蛋白缓解	尿红细胞缓解	完全缓解	ESRD	NOS
冯凤仪(2006)^[12]	中国	PC	32/34	7.4	40/26	T+S	S	0.5	-		22/12		7
黄远航(2009)^[13]	中国	R	109/98	30.7	114/93	T+S	S	1.0	-		89/50		7
江枫(2008)^[14]	中国	PC	35/40	-	38/37	T	S	0.5	-		16/13	2/8	7
刘虹(2009)^[15]	中国	CC	57/51	32.0	56/52	T+S	S	1.0	-		47/22		7
孟骏(2012)^[16]	中国	PC	24/18	31.6	16/26	T+S	S	1.0	19/8	18/3	15/3		7
田滨瑶(2022)^[17]	中国	R	34/49	32.7	42/41	T/T+S/T+I/T+S+I	S/I/S+I/保守治疗	3.9	-		17/17		7
吴和燕(2020)^[18]	中国	R	40/80	14.3	70/50	T+S	S	8.1	-		29/36	2/4	8
肖爱华(2007)^[19]	中国	PC	12/15	21.4	17/10	T	S	0.5	-		10/2		7
于二峰(2019)^[20]	中国	PC	59/31	30.3	34/56	T+S	S	3.0	47/13	49/9			7
俞雨生(1991)^[21]	中国	PC	41/39	25.4	59/21	T	S	1.5	-		19/9		7
Akagi(2004)^[22]	日本	RCC	41/30	31.1	32/39	T+S	S	13.0	-		10/4	2/8	8
Chen(2007)^[23]	中国	RCC	54/58	27.3	66/46	T+S	S	10.8	-		25/16	2/7	8
Feehally(2016)^[24]	意大利	MRCS	41/41	35.5	42/40	T+S	S	3.3	-			3/8	7
Hirano(2019)^[25]	日本	MRCS	252/813	35.0	535/530	T+无S/S/SP	无S/S/SP	5.8	-			11/118	8
Hoshino(2016)^[26]	日本	MCS	209/918	44.1	638/489	T+SP	SP/S/保守治疗	8.3	-			7/146	8
Hoshino(2017)^[27]	日本	RCS	26/26	32.6	18/34	T+SP	S	6.0	-		15/5		8
Hotta(2001)^[28]	日本	RCS	191/34	34.4	-	T+S/SP	S/SP	6.9	-		114/12		8
Hotta(1993)^[29]	日本	PC	26/19	30.2	17/28	T+SP	SP	3.0	14/5	20/8			7
Katafuchi(2016)^[30]	日本	RCT	26/33	39.2	27/32	T+S	S	4.8	16/13	18/20	12/9		-
Kawaguchi(2010)^[31]	日本	RCS	307/81	34.3	177/211	T+S or T	S	5.0	-		197/19		8
Kawamura(2014)^[32]	日本	MRCT	33/39	38.2	35/37	T+S	S	1.0	20/14	22/23	15/10		-
Kawasaki(2006)^[33]	日本	PC	16/16	12.2	17/15	T+SP	S	2.0	-		12/9		7
Komatsu(2008)^[34]	日本	PNC	35/20	34.5	21/34	T+S	S	4.5	23/7	27/9	19/5	0/1	7
Komatsu(2016)^[35]	日本	MRCS	46/33	34.9	31/48	T+S	S or保守治疗	4.7	37/15	38/18	33/14	0/1	7
Maeda(2012)^[36]	日本	RCS	70/130	31.7	67/133	T+S/SP	S+SP	5.2	-		24/12		8
Matsumoto(2018)^[37]	日本	RCS	87/87	31.0	68/106	T+S/SP	S+SP	7.8	-			6/22	8
Miyamoto(2016)^[38]	日本	MRCS	161/123	37.3	123/161	T+S	S or保守治疗	4.1	-		92/49		7
Miyazaki(2007)^[39]	日本	MPCS	78/23	34.4	43/58	T or T+S	S or保守治疗	5.0	-		52/10		8
Nishi(2004)^[40]	日本	R	46/74	32.6	69/51	T+S	S	16.4	-			5/19	8
Ochi(2013)^[41]	日本	RCS	26/15	31.1	15/26	T+S	S	1.0	20/8	23/5	18/2		7
Ogura(2021)^[42]	日本	RCS	32/80	32.0	49/63	T+S	S or保守治疗	5.0	26/37	26/37	24/31	0/0	8
Ohya(2013)^[43]	日本	RCS	41/21	34.6	20/42	T+S	S	5.8	-		24/10		8
Rasche(1999)^[44]	日本	RCS	16/39	29.0	38/17	T+S	S	3.4	-			10/14	7
Sato(2003)^[45]	日本	RCS	30/40	46.5	51/19	T+S	S or保守治疗	5.9	-			4/25	8
Xie(2003)^[46]	日本	RCS	48/70	32.3	64/54	T+S	S	16.1	-			5/18	8
Yang(2016)^[47]	中国	RCT	49/49	30.0	45/53	T+S	S	4.0	47/25	45/23			-

作者(年份)	选择				基于设计或分析的队列的可比性	结局			总分
作者(年份)	暴露队列的代表性	非暴露队列的选择	暴露的确定	研究开始前没有研究对象出现结局事件	基于设计或分析的队列的可比性	结局事件的评估	为观察到结局事件, 随访是否充分	随访的完整性	总分
冯凤仪(2006)	★	★	★	★	★★	★	☆	☆	7
黄远航(2009)	★	★	★	★	★★	★	☆	☆	7
江枫(2008)	★	★	★	★	★★	★	☆	☆	7
刘虹(2009)	★	★	★	★	★★	★	☆	☆	7
孟骏(2012)	★	★	★	★	★★	★	☆	☆	7
田滨瑶(2022)	★	★	★	★	★★	★	☆	☆	7
吴和燕(2020)	★	★	★	★	★★	★	★	☆	8
肖爱华(2007)	★	★	★	★	★★	★	☆	☆	7
于二峰(2019)	★	★	★	★	★★	★	☆	☆	7
俞雨生(1991)	★	★	★	★	★★	★	☆	☆	7
Akagi(2004)	★	★	★	★	★★	★	★	☆	8
Chen(2007)	★	★	★	★	★★	★	★	☆	8
Feehally(2016)	★	★	★	★	★★	★	☆	☆	7
Hirano(2019)	★	★	★	★	★★	★	★	☆	8
Hoshino(2016)	★	★	★	★	★★	★	★	☆	8
Hoshino(2017)	★	★	★	★	★★	★	★	☆	8
Hotta(2001)	★	★	★	★	★★	★	★	☆	8
Hotta(1993)	★	★	★	★	★★	★	☆	☆	7
Kawaguchi(2010)	★	★	★	★	★★	★	★	☆	8
Kawasaki(2006)	★	★	★	★	★★	★	☆	☆	7
Komatsu(2008)	★	★	★	★	★★	★	☆	☆	7
Komatsu(2016)	★	★	★	★	★★	★	☆	☆	7
Maeda(2012)	★	★	★	★	★★	★	★	☆	8
Matsumoto(2018)	★	★	★	★	★★	★	★	☆	8
Miyamoto(2016)	★	★	★	★	★★	★	☆	☆	7
Miyazaki(2007)	★	★	★	★	★★	★	★	☆	8
Nishi(2004)	★	★	★	★	★★	★	★	☆	8
Ochi(2013)	★	★	★	★	★★	★	☆	☆	7
Ogura(2021)	★	★	★	★	★★	★	★	☆	8
Ohya(2013)	★	★	★	★	★★	★	★	☆	8
Rasche(1999)	★	★	★	★	★★	★	☆	☆	7
Sato(2003)	★	★	★	★	★★	★	★	☆	8
Xie(2003)	★	★	★	★	★★	★	★	☆	8

作者(年份)	选择				基于设计或分析的队列的可比性	结局			总分
作者(年份)	暴露队列的代表性	非暴露队列的选择	暴露的确定	研究开始前没有研究对象出现结局事件	基于设计或分析的队列的可比性	结局事件的评估	为观察到结局事件, 随访是否充分	随访的完整性	总分
冯凤仪(2006)	★	★	★	★	★★	★	☆	☆	7
黄远航(2009)	★	★	★	★	★★	★	☆	☆	7
江枫(2008)	★	★	★	★	★★	★	☆	☆	7
刘虹(2009)	★	★	★	★	★★	★	☆	☆	7
孟骏(2012)	★	★	★	★	★★	★	☆	☆	7
田滨瑶(2022)	★	★	★	★	★★	★	☆	☆	7
吴和燕(2020)	★	★	★	★	★★	★	★	☆	8
肖爱华(2007)	★	★	★	★	★★	★	☆	☆	7
于二峰(2019)	★	★	★	★	★★	★	☆	☆	7
俞雨生(1991)	★	★	★	★	★★	★	☆	☆	7
Akagi(2004)	★	★	★	★	★★	★	★	☆	8
Chen(2007)	★	★	★	★	★★	★	★	☆	8
Feehally(2016)	★	★	★	★	★★	★	☆	☆	7
Hirano(2019)	★	★	★	★	★★	★	★	☆	8
Hoshino(2016)	★	★	★	★	★★	★	★	☆	8
Hoshino(2017)	★	★	★	★	★★	★	★	☆	8
Hotta(2001)	★	★	★	★	★★	★	★	☆	8
Hotta(1993)	★	★	★	★	★★	★	☆	☆	7
Kawaguchi(2010)	★	★	★	★	★★	★	★	☆	8
Kawasaki(2006)	★	★	★	★	★★	★	☆	☆	7
Komatsu(2008)	★	★	★	★	★★	★	☆	☆	7
Komatsu(2016)	★	★	★	★	★★	★	☆	☆	7
Maeda(2012)	★	★	★	★	★★	★	★	☆	8
Matsumoto(2018)	★	★	★	★	★★	★	★	☆	8
Miyamoto(2016)	★	★	★	★	★★	★	☆	☆	7
Miyazaki(2007)	★	★	★	★	★★	★	★	☆	8
Nishi(2004)	★	★	★	★	★★	★	★	☆	8
Ochi(2013)	★	★	★	★	★★	★	☆	☆	7
Ogura(2021)	★	★	★	★	★★	★	★	☆	8
Ohya(2013)	★	★	★	★	★★	★	★	☆	8
Rasche(1999)	★	★	★	★	★★	★	☆	☆	7
Sato(2003)	★	★	★	★	★★	★	★	☆	8
Xie(2003)	★	★	★	★	★★	★	★	☆	8

作者(年份)	蛋白尿缓解	血尿缓解	临床缓解	ESRD
冯凤仪(2006)	-	-	术后半年肉眼血尿消失,1 h尿沉渣红细胞计数、24 h尿蛋白定量恢复正常	-
黄远航(2009)	-	-	尿蛋白定量持续<0.15 g/24 h,尿红细胞<8000/ml	-
江枫(2008)	-	-	肾功能正常,半年以上血尿、蛋白尿阴性	终末期肾衰竭行透析或肾移植治疗
刘虹(2009)	-	-	尿红细胞<8000/ml,尿蛋白24 h持续<0.15 g	-
孟骏(2012)	尿蛋白消失	尿潜血消失	尿蛋白或尿潜血消失	-
田滨瑶(2022)	-	-	尿蛋白转阴,24 h尿蛋白定量<0.3 g/d,血清白蛋白(ALB)>35 g/L,肾功能不全者血肌酐(sCr)下降或稳定	-
吴和燕(2020)	-	-	肾功能正常,蛋白尿和血尿阴性(尿蛋白量<0.4 g/24 h,尿红细胞<10⁴/ml),且随访期间无复发	初始估算肾小球滤过率(eGFR)<15 ml·min^-1/1.73 m²或需要接受肾脏替代治疗
肖爱华(2007)	-	-	24 h尿蛋白定量、1 h尿红细胞计数恢复正常	-
于二峰(2019)	尿蛋白较基础值下降 ≤0.3 g/d	尿红细胞较基础值减少 ≤2.0万/ml	-	-
俞雨生(1991)	-	-	肉眼血尿消失,尿化验阴性,血浆蛋白及肾功能正常,临床症状体征消失	-
Akagi(2004)	-	-	肾功能正常,无蛋白尿和血尿	需要透析的患者
Chen(2007)	-	-	随访期间肾功能正常,蛋白尿和血尿呈阴性(尿蛋白排泄量<0.4 g/d,尿红细胞<10000个/ml),无复发	sCr水平超过8 mg/dl(707 μmol/L)或进行透析或肾移植
Feehally(2016)	-	-	-	eGFR降低50%或终末期肾病
Hirano(2019)	-	-	-	首次出现sCr从基线或透析开始增加1.5倍
Hoshino(2016)	-	-	-	开始透析治疗
Hoshino(2017)	-	-	在6个月内观察到3次24h蛋白尿<0.3 g/gCr或0.3 g/d,尿红细胞<5/HPF	-
Hotta(2001)	-	-	尿蛋白和血尿阴性,尿红细胞为4/高倍视野或更低	-
Hotta(1993)	持续3个月蛋白尿<100 mg/d	持续3个月<3红细胞/HP		-
Katafuchi(2016)	尿蛋白排泄量<0.3 g/d,或<0.3 g/g Cr	尿沉渣中的红细胞数量<5/HPF	蛋白尿和血尿消失	-
Kawaguchi(2010)	-	-	尿蛋白完全消失,尿红细胞小于1/高倍视野	-
Kawamura(2014)	蛋白尿消失	血尿消失	蛋白尿和(或)血尿消失	-
Kawasaki(2006)	-	-	尿液和肾功能正常	-
Komatsu(2008)	蛋白尿消失	血尿消失	蛋白尿和(或)血尿消失	sCr比基线水平增加100%
Komatsu(2016)	至少连续2次24 h尿蛋白<0.3 g/d,尿蛋白/尿肌酐比值<0.3或尿蛋白定性(-)~(±)	至少连续两次在尿沉渣镜检<5/HPF或浸棒试验中红细胞(-)~(±)	血尿和蛋白尿消失	肾功能下降50%,sCr较基线升高100%,或肾脏替代治疗
Maeda(2012)	-	-	至少相隔3个月连续2次就诊时血尿和蛋白尿正常	-
Matsumoto(2018)	-	-		-
Miyamoto(2016)	-	-	至少连续2次蛋白尿和血尿的缓解:蛋白尿为阴性或微量或尿蛋白排泄量<0.3 g/g Cr;尿沉渣中的红细胞数量<5/HPF	-
Miyazaki(2007)	-	-	-	-
Nishi(2004)	-	-	-	开始透析治疗
Ochi(2013)	24 h蛋白尿<0.3 g/g Cr	尿红细胞<5/HPF	24 h蛋白尿<0.3 g/g Cr和尿红细胞<5/HPF	-
Ogura(2021)	连续3次发现24 h蛋白尿<0.3 g/g Cr或尿蛋白定性(-)或(±)	连续3次发现红细胞<5/HPF或定性测量(-)或(±)	血尿和蛋白尿缓解	开始透析治疗
Ohya(2013)	-	-	尿蛋白或尿潜血消失	-
Rasche(1999)	-	-	-	开始透析治疗
Sato(2003)	-	-	-	开始透析治疗
Xie(2003)	-	-	-	开始透析治疗
Yang(2016)	尿蛋白<0.3 g/d	尿沉渣中的红细胞<5/HPF	蛋白尿和血尿消失	-