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目的比较霉酚酸酯(MMF)与间断环磷酰胺(CTX)静脉冲击疗法对Ⅳ型狼疮性肾炎(LN)伴非炎症坏死性血管病变(NNV)的疗效。方法20例系统性红斑狼疮患者经肾活检确诊为Ⅳ型LN伴间质NNV,分别采用激素联合MMF(MMF组,n=9)或激素联合CTX静脉冲击疗法(CTX组,n=11),MMF剂量1.5~2.0g/d,;CTX剂量为0.75~1g/m2.BSA,每月静脉滴注一次。两组患者基础病情相似,比较两组治疗6个月的临床疗效和不良反应。临床疗效分为完全缓解[尿蛋白定量<0.4g/24h,尿红细胞(RBC)计数<10万/ml,无管型及白细胞尿,血清白蛋白≥35g/L,血肌酐(SCr)正常]和部分缓解(尿蛋白下降超过基础值50%且<2g/24h,尿红细胞计数及SCr下降超过基础值50%,血浆白蛋白≥30g/L)。结果MMF失访1例,CTX组失访2例。诱导治疗6月MMF组3例(37.5%)完全缓解,而CTX组无一例完全缓解,P=0.08,部分缓解例数分别为MMF组3例(37.5%)和CTX组3例(33.3%)。尿RBC<10万/ml比例MMF组高于CTX组(75%vs0,P<0.01)。尿蛋白转阴(尿蛋白定量<0.4g/24h)比例MMF组亦高于CTX组(62.5%vs11.1%,P<0.05)。治疗前MMF组5例、CTX组6例SCr增高,治疗6月两组均有1例SCr未降至正常。MMF组1例(12.5%)并发带状疱疹,CTX组5例(55.5%)发生不良反应,包括胃肠道症状(3例),白细胞减少(1例),肝酶升高(1例)。结论激素联合MMF对伴NNV病变的Ⅳ型LN近期疗效优于CTX,但需要扩大病例数长期随访,并探索更为有效的治疗方法。
Objective To compare the efficacy of mycophenolate mofetil (MMF) and intermittent cyclophosphamide (CTX) intravenous shock therapy on type Ⅳ lupus nephritis (LN) with non-inflammatory necrotic vascular lesions (NNV). Methods Twenty patients with systemic lupus erythematosus were diagnosed as type IV LN with interstitial NNV by renal biopsy. Hormone and MMF (n = 9) or hormone combined with CTX (n = 11) MMF dose of 1.5 ~ 2.0g / d ,; CTX dose of 0.75 ~ 1g / m2.BSA, intravenous infusion once a month. The two groups of patients with similar basic conditions, the two groups were compared for 6 months of clinical efficacy and adverse reactions. Clinical efficacy was divided into complete remission [urinary protein quantitation <0.4g / 24h, RBC counts <100,000 / ml, tubular and leukocyturia, serum albumin ≥ 35g / L, normal serum creatinine (SCr) And partial remission (urinary protein decreased more than 50% of the baseline value and <2g / 24h, urinary erythrocyte count and SCr decreased more than 50% of the basal value, plasma albumin ≥ 30g / L). Results One patient lost MMF and two patients lost CTX. Three patients (37.5%) in MMF group were completely relieved in induction therapy, but none in CTX group was completely relieved (P = 0.08). The partial response rates were 3 cases (37.5%) in MMF group and 3 cases (33.3%) in CTX group . Urine RBC <100,000 / ml MMF group was higher than CTX group (75% vs0, P <0.01). Urinary protein negative (urine protein <0.4g / 24h) ratio of MMF group was also higher than CTX group (62.5% vs11.1%, P <0.05). Before treatment, 5 cases of MMF group and 6 cases of CTX group showed an increase of SCr. One case of SCr did not decrease to normal in both groups. In the MMF group, 1 patient (12.5%) had shingles and 5 patients (55.5%) in the CTX group had adverse reactions, including gastrointestinal symptoms (3 cases), leukopenia (1 case), elevated liver enzymes (1 case) . Conclusion The combination of hormones and MMF is superior to CTX in the treatment of type Ⅳ LN with NNV. However, it is necessary to expand the number of patients with long-term follow-up and to explore more effective treatment.