急性感染后新月體腎炎課件

--感染后新月體腎炎溫州醫(yī)學(xué)院附屬第一醫(yī)院陳天新急性感染后腎小球腎炎主要內(nèi)容討論病例臨床診斷的個(gè)人觀點(diǎn)兒童感染后新月體腎炎的相關(guān)文獻(xiàn)報(bào)道成人感染后腎炎的病例報(bào)道和臨床研究主要內(nèi)容討論病例臨床診斷的個(gè)人觀點(diǎn)兒童感染后新月體腎炎的相關(guān)文獻(xiàn)報(bào)道成人感染后腎炎的病例報(bào)道和臨床研究感染后第19天第31天第40天第46天第51天第58天日期9.169.2810.710.1310.1810.25

9.27甲強(qiáng)龍沖擊為什么不診斷為急進(jìn)性腎炎患者在用激素沖擊前腎功能已好轉(zhuǎn)，而不是進(jìn)行性惡化。因此我認(rèn)為臨床上不符合急進(jìn)性腎炎。急進(jìn)性腎炎為急性快速進(jìn)展性腎小球腎炎（acuterapidlyprogressiveglomerulonephritis，ARPG）的簡(jiǎn)稱。它起病急驟，可在數(shù)日、數(shù)周或數(shù)月內(nèi)腎功能急劇惡化，以少尿（無(wú)尿）性急性腎功能衰竭為多見。急性腎炎綜合征進(jìn)行性腎功能損害。新月體性腎炎ARPG特征：臨床：病理：腎小球彌漫性毛細(xì)血管內(nèi)中重度增生伴毛細(xì)血管腔閉塞及多核白細(xì)胞滯留－－典型APGN病理

26個(gè)腎小球，7個(gè)球性硬化，11個(gè)腎小球見大型細(xì)胞性新月體。（IF）以IgA及C3沉積最強(qiáng)，呈顆粒狀，腎小球毛細(xì)血管壁及系膜區(qū)分布為主。病理特點(diǎn)結(jié)合臨床病理，可診斷：感染后新月體腎炎。新月體腎炎急進(jìn)性腎炎感染后新月體腎炎比較少見（占腎活檢標(biāo)本4.6％）相比而言，老年人易出現(xiàn)感染細(xì)菌：鏈球菌，金黃色葡萄球菌，革蘭氏陰性桿菌等。Anupdateonacutepostinfectiousglomerulonephritisworldwide.Kanjanabuch,T.etal.Nat.Rev.Nephrol.5,259–269(2009)感染后腎炎絕大部分未行腎活檢活檢時(shí)機(jī)和指征不一樣，新月體比例也不一樣因此，確切的發(fā)病率無(wú)法統(tǒng)計(jì)和報(bào)道Pediatrics1975新月體腎炎例數(shù)鏈感后隨訪預(yù)后171018to57months鏈感后預(yù)后較好TheJournalofPediatrics1981鏈感后新月體腎炎pre+ctx/aza支持治療預(yù)后10例（Ccr<30)5例5例兩組預(yù)后無(wú)顯著差別KI1985新月體腎炎例數(shù)鏈球菌感染后低補(bǔ)體血癥預(yù)后50（平均GFR42)占34％占48％鏈感后新月體腎炎呈自限性，預(yù)后較好AmJofnephrology1992largecrescentsinmorethan50%oftheglomeruli鏈感后新月體腎炎急進(jìn)性腎炎/非ARPG預(yù)后43例1131/1223CRF,14CRI,6recover;11APSGN中，7CRF,2CRI,2recover。主要內(nèi)容討論病例臨床診斷的個(gè)人觀點(diǎn)兒童感染后新月體腎炎的相關(guān)文獻(xiàn)報(bào)道成人感染后腎炎的病例報(bào)道和臨床研究Long‐termprognosisofdiffuseproliferativeglomerulonephritisassociatedwithinfectioninadults

GabriellaMoroni1,ClaudioPozzi2,SilvanaQuaglini3,

Nephrol.Dial.Transplant.-2002病例入選標(biāo)準(zhǔn)：臨床生化和病理標(biāo)準(zhǔn)至少各2條Clinical/biochemicalcriteriaincluded(i)arecentepisodeofinfection,(ii)antistreptolysinOtitre>250?IU/l(iii)atransientreductionofserumcomplementfractions.Histologicalcriteriaincluded(i)diffuseproliferativeand/orexudativeglomerulonephritis,(ii)dominantgranularimmune‐depositsofIgGand/orC3inthesubepithelialpositionatimmunofluorescence(caseswithfaintdepositsofIgAwereincludedaccordingtoSilva[7])(iii)presenceofhumpsonelectronmicroscopy.Exclusioncriteriawere:predominantIgAdepositsonimmunofluorescence;idiopathicmembranoproliferativeglomerulonephritis;cryoglobulinaemicnephritis;lupusnephritis.Theinfectiveagentsculturedfromthesitesofinfection:Streptococcushaemolyticus(5patients),

Staphylococcusaureus(6patients),Escherichiacoli(8patients),Pseudomonasaeruginosa(綠膿桿菌2patients),

Haemophilusinfluenzae(嗜血桿菌1patient).21ofthe45patientsevaluatedhadhighantistreptolysintitre.ClinicalcharacteristicsofpatientsatpresentationGroup1(29patients)Group2(21patients)P

TotalAge(years)47(18–62)62(48–70)0.0154(30–66)Sex(M/F)14/1516/5n.s.30/20Plasmacre(mg/dl)1.5(1–4)3.0(1.4–4.3)n.s.2.15(1.2–4.1)Proteinuria(g/24?h)3.5(0.7–6.1)7.1(2.5–11.5)0.053.7(1.8–9)hypertension19(68%)14(67%)n.s.33steroidtherapy（n）1311Group1：

APIGNwithoutotherunderlyingdisease(29patients).Group2:APIGNwithsevereunderlyingdisease(21patients),

9livercirrhosis,

4malignantneoplasia,5DM（其中3例有肝硬化）,3COPD,1地中海貧血，1肌炎，1磷脂抗體綜合征。C3(2+or3+)291847(94)

IgG(2+or3+)18

8n.s.26(52)

IgM(1+)

6130.0119(38)

C1q(1+)

6

3n.s.

9(18)

IgA(1+)

5

90.0914(28)

Starryskypattern14

620(40)

Garlandpattern

2

1

3(6)

Mesangialpattern

1

1

2(4)Renalstatusof49patientsatthelastobservationGroup1Group2TotalCompleteremission(numberofpatients)

18(64%)

3(14%)

21(43%)

Follow‐up(months)145(55–219)54(52–62)138(60–211)Partialremission(n)

5(18%)

5(24%)

10(20%)

Follow‐up(months)

20(12–99)31(18–53)

38(21–107)

Plasmacreatinine(mg/dl)

1(0.9–1.1)1.2(0.7–1.3)

1(0.9–1.2)

Proteinuria(g/24?h)

1(0.8–2.4)

1(0.8–2)

1(0.6–2)

Microscopichaematuria（n）

4

5

9Remission(21)Noremission(28)PAge(years,median)47(17–58)63(42–68)0.08Underlyingdiseases(%)14.364.30.01Proteinuria(g/24?h,median)3.7(0.7–6)4.7(2.3–10.3)0.06Extracapillaryproliferation(%)14610.03Interstitialinfiltration(%)5570.017Subendothelialdepositsonelectronmicroscopy(%)19680.05Clinicalandhistologicalpredictorsofcompleteremission:univariateanalysisAtmultivariateanalysisonlytheabsenceof