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目的:比较霉酚酸酯(MMF)与间断环磷酰胺(CTX)静脉冲击疗法治疗弥漫增生性狼疮性肾炎(Ⅳ)伴膜性病变型(Ⅴ型)狼疮性肾炎(Ⅳ+Ⅴ型LN)的临床疗效。方法:2000年1月至2004年1月间在解放军肾脏病研究所对经肾穿刺活检诊断为Ⅳ+Ⅴ型LN患者43例,比较同期激素联合MMF(MMF组,n=20),与激素联合CTX间断静脉冲击治疗(CTX组,n=23例)的疗效。MMF剂量1.5g/d或2g/d;CTX剂量为0.75～1g/m2·体表面积,每月静脉滴注一次。除MMF组血清肌酐高于CTX组外,其它基础病情两组相似。比较两组治疗6个月的完全缓解率、部分缓解率。结果:(1)临床缓解率:治疗6个月时MMF组缓解率高于CTX组:完全缓解率分别为20%和4.4%(P<0.05),部分缓解率分别为60%和34.8%(P<0.05)。(2)尿蛋白及尿红细胞变化:MMF组尿蛋白完全缓解率(≤0.4g/24h)高于CTX组(20%vs4.4%,P<0.05),红细胞缓解率也高于CTX组(63%vs50%,P>0.05)。(3)自身抗体变化:MMF与CTX组患者分别有78.9%及69.6%血清抗dsDNA转阴,ANA转阴率分别为36.9%和8.7%(P<0.05)。(4)肾脏病理变化:5例行重复肾活检。MMF组2例达部分缓解,肾小球增生性病变及血管炎性病变消失,上皮侧沉积物未减少,CTX组3例(1例部分缓解,2例无效)仍见增生性病变及袢坏死,2例未缓解者上皮侧沉积物增多。(5)副作用:MMF组并发带状疱疹2例,上呼吸道感染、白细胞减少各1例,CTX组2例并发带状疱疹及细菌性肺炎,4例有明显消化道症状,各有1例并发白细胞减少、肝酶升高和脱发。结论:激素联合MMF治疗Ⅳ+Ⅴ型狼疮性肾炎6个月的临床缓解率高于CTX,但绝大部分仅获部分缓解,对此类型LN最佳治疗方法仍需进一步临床研究。
OBJECTIVE: To compare the efficacy of mycophenolate mofetil (MMF) and intermittent cyclophosphamide (CTX) in the treatment of diffuse proliferative lupus nephritis (IV) with membranous lesion (Ⅴ type) lupus nephritis (Ⅳ + Ⅴ LN) Clinical efficacy. Methods: From January 2000 to January 2004, 43 patients with type Ⅳ and type Ⅴ LN diagnosed by renal biopsy in the PLA Institute of Nephrology were compared. Hormone and MMF Combined CTX intermittent venous pulse therapy (CTX group, n = 23). MMF dose of 1.5g / d or 2g / d; CTX dose of 0.75 ~ 1g / m2 body surface area, a monthly intravenous infusion. Except MMF group serum creatinine higher than the CTX group, the other basic conditions similar to the two groups. The complete remission rate and partial remission rate were compared between the two groups for 6 months. Results: (1) Clinical remission rate: At 6 months, the remission rate of MMF group was higher than that of CTX group: the complete remission rate was 20% and 4.4% respectively (P <0.05), and the partial remission rates were 60% and 34.8% P <0.05). (2) Urinary protein and urinary erythrocyte changes: The complete remission rate of urinary protein in MMF group (≤0.4g / 24h) was higher than CTX group (20% vs4.4%, P <0.05) 63% vs 50%, P> 0.05). (3) The changes of autoantibody: 78.9% and 69.6% of serum anti-dsDNA were negative in patients with MMF and CTX respectively. The negative rate of ANA was 36.9% and 8.7% respectively (P <0.05). (4) renal pathological changes: 5 cases of repeated renal biopsy. In MMF group, 2 cases were partially relieved, glomerular proliferative lesions and vasculitic lesions disappeared, and the epithelial side deposits did not decrease. In CTX group, 3 cases (1 partial response and 2 ineffective) still showed hyperplastic lesions and necrosis , 2 cases of undifferentiated epithelial side sediment increased. (5) side effects: MMF group complicated with shingles in 2 cases, upper respiratory tract infection, leukopenia in 1 case, 2 cases of CTX group complicated with shingles and bacterial pneumonia, 4 cases had obvious gastrointestinal symptoms, each with 1 case complicated Leukopenia, elevated liver enzymes and hair loss. Conclusion: The clinical remission rate of steroid combined with MMF for Ⅳ + Ⅴ lupus nephritis at 6 months is higher than that of CTX, but most of them are only partially relieved. The best treatment for this type of LN still needs further clinical study.