体质量指数对IgA肾病患者临床病理及预后的影响

doi:10.3969/j.issn.1004-583X.2022.03.007

摘要/Abstract

摘要：

目的探讨人体质量指数(body mass index, BMI)对IgA肾病(IgA nephropathy, IgAN)患者的临床病理及其预后的影响。方法回顾性分析2013年2月至2021年5月在青岛大学附属医院就诊并经肾穿刺活检确诊为原发性IgAN的初治患者的临床病理资料及预后,终点事件为血肌酐翻倍和(或)进入终末期肾病(end-stage renal disease, ESRD)和(或)肾替代治疗和(或)死亡。根据患者接受肾活检时的BMI及WHO肥胖分类分组如下:低体重组(BMI<18.5 kg/m²)、正常体重组(18.5≤BMI<25.0 kg/m²)和超重肥胖组(BMI≥25.0 kg/m²)。比较各组临床病理资料、预后的差异。采用Kaplan-Meier生存曲线评估患者肾脏累计生存率,多因素Cox回归分析影响IgAN合并超重肥胖患者肾脏预后的危险因素。结果共入选533例IgAN患者,其中低体重组19例(3.6%),正常体重组267例(50.1%),超重肥胖组247例(46.3%)。与低体重组、正常体重组比较,超重肥胖组的年龄、收缩压、舒张压、血管紧张素转换酶抑制剂(angiotensin-converting-enzyme inhibitors,ACEI)/血管紧张素Ⅱ 1型受体拮抗剂(angiotensin Ⅱ receptor type 1,ARB)使用占比、血红蛋白、24小时尿蛋白排泄量、甘油三酯、空腹血糖、血清补体C3、血清补体C4、尿酸较高,而高密度脂蛋白胆固醇(high-density lipoprotein cholesterol,HDL-C)、估算的肾小球滤过率(estimated glomerular filtration rate,eGFR)水平较低(均P<0.05)。正常体重组年龄、收缩压、舒张压、ACEI/ARB使用比例、尿酸高于低体重组,而eGFR低于低体重组(均P<0.05)。超重肥胖组和正常体重组的低密度脂蛋白胆固醇(low-density lipoprotein cholesterol,LDL-C)高于低体重组(均P<0.05)。与正常体重组比较,超重肥胖组的免疫球蛋白M水平较低,男性占比、C反应蛋白(C-reactive protein,CRP)水平较高(均P<0.05)。低体重组的中性粒细胞计数高于正常体重组(P<0.05)。光镜检查结果显示,超重肥胖组、正常体重组的血管损伤程度、炎细胞浸润程度高于低体重组(均P<0.05)。与正常体重组比较,超重肥胖组的系膜C3沉积减弱(P<0.05)。Kaplan-Meier生存曲线分析表明,正常体重组的肾脏累积生存率高于超重肥胖组(Log-rank检验,χ²=8.702,P=0.003),而超重肥胖组肾脏累积生存率高于低体重组(Log-rank检验,χ²=4.624,P=0.032)。3组的肾脏5年生存率分别为69.8%、75.6%、85.9%,正常体重组的5年肾脏生存率高于超重肥胖组(Log-rank检验,χ²=4.996,P=0.025),而超重肥胖组的5年生存率高于低体重组(Log-rank检验,χ²=5.764,P=0.016)。在IgAN合并超重肥胖患者中,多因素Cox回归分析结果提示,24小时尿蛋白排泄量、甘油三酯、血红蛋白是发生肾脏终点事件的独立危险因素。结论 IgAN合并超重肥胖患者临床表现较重,有着更重的血管损伤及炎细胞浸润,肾脏预后较差。应重视IgAN合并超重肥胖患者的治疗及随访过程中生活方式及体重的管理。

关键词: 肾小球肾炎, IGA, 人体质量指数, 病理学, 预后

Abstract:

Objective To investigate the impact of body mass index (BMI) on the clinicopathology and prognosis of patients with IgA nephropathy (IgAN). Methods The clinicopathological data and prognosis of 533 primary IgAN patients who were diagnosed by renal biopsy in the Affiliated Hospital of Qingdao University from February 2013 to May 2021 were retrospectively analyzed.Serum creatinine levels doubling and/or entered end-stage renail disease(ERSD) and/or renal replacement therapy and/or death were endpoints.According to the BMI and World Health Organization (WHO) obesity classification, the patients were grouped as follows: low body weight group (BMI<18.5 kg/m²), normal weight group (18.5≤BMI<25.0 kg/m²) and overweight obese group (BMI≥25.0 kg/m²). The differences in clinicopathological and prognosis of of patients in each group were compared.The Kaplan-Meier survival curve was used to assess the cumulative renal survival rate of patients, and the multifactorial Cox regression analysis was used to analyze the risk factors affecting the renal prognosis of IgAN patients with overweight and obesity. Results In 533 IgAN patients, 19 patients (3.6%) were underweight, 267 patients (50.1%) were normal weight, and 247 patients (46.3%) were obese weight. Compared with low body weight group and normal weight group, the overweight obese group showed increased age, systolic blood pressure (SBP), diastolic blood pressure (DBP), angiotensin-converting-enzyme inhibitors(ACEI)/angiotensin II receptor type 1(ARB)use ratio, hemoglobin, 24-hour urinary protein excretion, triglycerides, fasting plasma glucose, blood complement C3 and C4 levels, and uric acid, and decreased HDL-C and eGFR levels (all P<0.05). In comparison of normal group and low group, normal group displayed increased age, SBP, DBP, ACEI/ARB use ratio, uric acid, and decreased eGFR (all P<0.05). LDL-C levels were higher in both the overweight obese group and the normal group than in the low group (all P<0.05). IgM levels were lower and male prevalence and CRP levels were higher in the overweight obese group compared with the normal group (all P<0.05). Neutrophil counts were higher in the low group than in the normal group (P<0.05). In light microscopic examination, low group showed decreased the degree of vascular damage and inflammatory cell infiltration among three groups (all P<0.05). Mesangial deposition of C3 was weakened in the overweight obese group compared with the normal group (P<0.05). Kaplan-Meier survival curve analysis showed that the cumulative renal survival rate was higher in the normal group than in the overweight obese group (Log-rank test, χ ²=8.702, P=0.003), whereas, which was higher in the overweight obese group than in the low group (Log-rank test, χ ²=4.624, P=0.032). 5-year renal survival rates were 69.8%, 75.6%, and 85.9%, for low group, overweight obese group and normal group respectively, with higher 5-year renal survival rates in the normal group than in the overweight obese group (Log-rank test, χ ²=4.996, P=0.025), and higher 5-year survival rates in the overweight obese group than in the low group (Log-rank test, χ ²=5.764, P=0.016). The multifactorial Cox regression analysis showed that 24-hour urinary protein excretion, triglycerides, and hemoglobin were risk factors for endpoint events in IgAN patients with overweight obese.Conclusion Among the IgAN patients, the clinical manifestations of overweight and obesity patients are worst characterized by severer vascular damage and inflammatory cell infiltration, poorer renal prognosis. Thus the therapeutic effect of those patients and follow-up lifestyle and weight management should be emphasized.

Key words: glomerulonephritis, IGA, body mass index, pathology, prognosis

中图分类号:

R692.31

高鹏丽, 陈丽丽, 田芬, 张嘉倩, 陈怿鹏, 亓晓菁, 邢广群. 体质量指数对IgA肾病患者临床病理及预后的影响[J]. 临床荟萃, 2022, 37(3): 234-242.

Gao Pengli, Chen Lili, Tian Fen, Zhang Jiaqian, Chen Yipeng, Qi Xiaojing, Xing Guangqun. Impact of body mass index in the clinicopathology and prognosis of patients with IgA nephropathy[J]. Clinical Focus, 2022, 37(3): 234-242.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2022.03.007

https://huicui.hebmu.edu.cn/CN/Y2022/V37/I3/234

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参考文献 45

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项目	低体重组(n=19)	正常体重组(n=267)	超重肥胖组(n=247)	F值/H值/χ²值	P值
年龄(岁)	27.95±8.28	38.13±12.71^*	42.4±13.84^*#	14.738	<0.01
性别[例(%)]
男女	8(42.2) 11(57.8)	124(46.4) 143(53.6)	149(60.3)^# 98(39.7)^#	10.810	<0.01
收缩压(mmHg)	119(110, 130)	130(120, 142)^*	138(130, 150)^*#	45.073	<0.01
舒张压(mmHg)	71(68, 78)	80(73, 90)^*	83(77, 92)^*#	22.211	<0.01
激素或免疫抑制剂治疗[例(%)]	7(36.8)	76(28.5)	73(29.6)	0.965	0.617
ACEI/ARB治疗[例(%)]	2(10.5)	110(41.2)^*	138(55.8)^*#	20.098	<0.01

项目	低体重组(n=19)	正常体重组(n=267)	超重肥胖组(n=247)	F值/H值/χ²值	P值
年龄(岁)	27.95±8.28	38.13±12.71^*	42.4±13.84^*#	14.738	<0.01
性别[例(%)]
男女	8(42.2) 11(57.8)	124(46.4) 143(53.6)	149(60.3)^# 98(39.7)^#	10.810	<0.01
收缩压(mmHg)	119(110, 130)	130(120, 142)^*	138(130, 150)^*#	45.073	<0.01
舒张压(mmHg)	71(68, 78)	80(73, 90)^*	83(77, 92)^*#	22.211	<0.01
激素或免疫抑制剂治疗[例(%)]	7(36.8)	76(28.5)	73(29.6)	0.965	0.617
ACEI/ARB治疗[例(%)]	2(10.5)	110(41.2)^*	138(55.8)^*#	20.098	<0.01

项目	低体重组(n=19)	正常体重组(n=267)	超重肥胖组(n=247)	H值/F值	P值
eGFR[ml/(min·1.73 m²)]	100.3±24.24	85.69±30.76^*	80.62±27.72^*#	5.063	<0.01
血红蛋白(g/L)	126.4±20.39	128.8±19.74	136.7±18.79^*#	11.725	<0.01
24小时尿蛋白排泄量(g/d)	1.38(0.25, 1.98)	1.13(0.58, 2.26)	2.01(0.98, 3.55)^*#	35.348	<0.01
CRP(mg/L)	1.99(1.15, 3.7)	1.33(0.79, 2.20)	1.88(1.05, 3.27)^#	15.372	<0.01
中性粒细胞计数(×10⁹/L)	4.66(3.94, 6.29)	3.61(2.90, 4.71)^*	3.96(3.14, 4.93)	12.833	<0.01
TC(mmol/L)	4.45(3.36, 5.04)	4.81(4.17, 5.79)	4.96(4.21, 6.21)	5.468	0.065
LDL-C(mmol/L)	2.08(1.45, 2.91)	2.95(2.41, 3.79)^*	3.14(2.44, 3.98)^*	12.098	<0.01
BUN(mmol/L)	4.92(3.93, 6.0)	5.88(4.60, 7.79)	5.94(4.60, 7.52)	4.417	0.110
血UA(μmol/L)	314.7±102.6	354.1±98.88^*	385.40±94.62^*#	9.528	<0.01
TG(mmol/L)	0.88(0.60, 1.37)	1.19(0.88, 1.76)	1.63(1.16, 2.43)^*#	46.493	<0.01
CysC(mg/L)	0.94(0.81, 1.57)	1.01(0.84, 1.34)	1.09(0.88, 147)	3.310	0.191
HDL-C(mmol/L)	1.45(1.22, 1.67)	1.36(1.16, 1.64)	1.18(1.02, 1.41)^*#	32.023	<0.01
FPG(mmol/L)	4.3(3.99, 4.62)	4.55(4.25, 4.85)	4.77(4.34, 5.23)^*#	25.039	<0.01
尿红细胞计数(个/μL)	51(19.1, 109.3)	65.34(22.8, 132.5)	56.60(21.12, 117.1)	1.842	0.398
尿白细胞计数(个/μL)	5.94(3.5, 16.7)	7.04(3.96, 13.8)	6.70(3.30, 14.30)	0.603	0.740
C1q(mg/L)	167(133.2, 202.3)	179(155.8, 205.3)	183(158.9, 205.4)	3.257	0.196
C3(g/L)	0.88(0.73, 1.03)	1.01(0.87, 1.14)	1.12(1.01, 1.28)^*#	54.860	<0.01
C4(g/L)	0.22(0.16, 0.26)	0.23(0.19, 0.28)	0.27(0.22, 0.32)^*#	29.190	<0.01
IgG(g/L)	10.90±3.33	10.13±3.49	9.99±3.53	0.561	0.571
IgE(IU/ml)	59.49(17.16, 155.80)	66.39(22.67, 149.70)	50.34(21.93, 141.80)	0.639	0.726
IgA(g/L)	3.14(2.37, 3.66)	2.92(2.36, 3.68)	3.04(2.32, 4.01)	1.070	0.586
IgM(g/L)	1.04(0.86, 1.58)	1.00(0.72, 1.41)	0.89(0.62, 1.25)^#	8.643	0.013

项目	低体重组(n=19)	正常体重组(n=267)	超重肥胖组(n=247)	H值/F值	P值
eGFR[ml/(min·1.73 m²)]	100.3±24.24	85.69±30.76^*	80.62±27.72^*#	5.063	<0.01
血红蛋白(g/L)	126.4±20.39	128.8±19.74	136.7±18.79^*#	11.725	<0.01
24小时尿蛋白排泄量(g/d)	1.38(0.25, 1.98)	1.13(0.58, 2.26)	2.01(0.98, 3.55)^*#	35.348	<0.01
CRP(mg/L)	1.99(1.15, 3.7)	1.33(0.79, 2.20)	1.88(1.05, 3.27)^#	15.372	<0.01
中性粒细胞计数(×10⁹/L)	4.66(3.94, 6.29)	3.61(2.90, 4.71)^*	3.96(3.14, 4.93)	12.833	<0.01
TC(mmol/L)	4.45(3.36, 5.04)	4.81(4.17, 5.79)	4.96(4.21, 6.21)	5.468	0.065
LDL-C(mmol/L)	2.08(1.45, 2.91)	2.95(2.41, 3.79)^*	3.14(2.44, 3.98)^*	12.098	<0.01
BUN(mmol/L)	4.92(3.93, 6.0)	5.88(4.60, 7.79)	5.94(4.60, 7.52)	4.417	0.110
血UA(μmol/L)	314.7±102.6	354.1±98.88^*	385.40±94.62^*#	9.528	<0.01
TG(mmol/L)	0.88(0.60, 1.37)	1.19(0.88, 1.76)	1.63(1.16, 2.43)^*#	46.493	<0.01
CysC(mg/L)	0.94(0.81, 1.57)	1.01(0.84, 1.34)	1.09(0.88, 147)	3.310	0.191
HDL-C(mmol/L)	1.45(1.22, 1.67)	1.36(1.16, 1.64)	1.18(1.02, 1.41)^*#	32.023	<0.01
FPG(mmol/L)	4.3(3.99, 4.62)	4.55(4.25, 4.85)	4.77(4.34, 5.23)^*#	25.039	<0.01
尿红细胞计数(个/μL)	51(19.1, 109.3)	65.34(22.8, 132.5)	56.60(21.12, 117.1)	1.842	0.398
尿白细胞计数(个/μL)	5.94(3.5, 16.7)	7.04(3.96, 13.8)	6.70(3.30, 14.30)	0.603	0.740
C1q(mg/L)	167(133.2, 202.3)	179(155.8, 205.3)	183(158.9, 205.4)	3.257	0.196
C3(g/L)	0.88(0.73, 1.03)	1.01(0.87, 1.14)	1.12(1.01, 1.28)^*#	54.860	<0.01
C4(g/L)	0.22(0.16, 0.26)	0.23(0.19, 0.28)	0.27(0.22, 0.32)^*#	29.190	<0.01
IgG(g/L)	10.90±3.33	10.13±3.49	9.99±3.53	0.561	0.571
IgE(IU/ml)	59.49(17.16, 155.80)	66.39(22.67, 149.70)	50.34(21.93, 141.80)	0.639	0.726
IgA(g/L)	3.14(2.37, 3.66)	2.92(2.36, 3.68)	3.04(2.32, 4.01)	1.070	0.586
IgM(g/L)	1.04(0.86, 1.58)	1.00(0.72, 1.41)	0.89(0.62, 1.25)^#	8.643	0.013

项目	低体重组(n=19)	正常体重组(n=267)	超重肥胖组(n=247)	F值/χ²值	P值
男性
例数	8	124	149
血红蛋白(g/L)	126.1±19.25	138.9±19.05	142.6±16.64^*	4.269	0.015
eGFR[ml/(min·1.73 m²)]	99.56±34.77	83.23±32.39	79.36±26.61	1.947	0.145
血UA(μmol/L)	382.9±120.7	397.6±96.8	409.6±95.2	0.554	0.575
女性
例数	11	143	98
血红蛋白(g/L)	126.5±22.11	120.0±15.77	127.0±15.55^#	2.711	<0.01
eGFR[ml/(min·1.73 m²)]	100.8±14.51	87.83±29.23	81.96±29.21^*	5.767	<0.01
血UA(μmol/L)	265.2±48.33	316.4±84.41	350.6±85.42^*#	8.026	<0.01