Objective To investigate the relationships of various types of renal vascular lesions with the clinical,pathological,and prognostic features of lupus nephritis (LN). Method A retrospective analysis was performed on the clinical and pathological data of LN patients treated in the Peking Union Medical College Hospital over the past 10 years to explore the relationships of different vascular lesions with clinical and pathological features and analyze the effects of renal vascular lesions on kidney prognosis from multiple perspectives. Results Among 644 enrolled LN patients,females accounted for 82.6%,and LN Ⅳ/Ⅳ+Ⅴ (60.4%) was the predominant pathological type.According to the types of renal vascular lesions,the patients were classified into four groups:atherosclerosis (AS)(n=171,26.6%),thrombotic microangiopathy (TMA)(n=78,12.1%),uncomplicated immune complex deposition (ICD)(n=29,4.5%),and lupus vasculopathy (LV)(n=19,3.0%). No renal vascular lesion (NRVL)(n=347,53.9%) was taken as the control group.The average age of patients in the AS group was higher than that in the other groups (all P<0.001).The TMA (P=0.009,P=0.025) and LV groups (P=0.007,P=0.005) had lower levels of complement C3,and higher disease activity index of systemic lupus erythematosus and incidence of acute kidney injury (both P<0.001) than the NRVL and AS groups.The TMA (P<0.001),LV (P<0.001),and AS (P=0.037) groups had lower estimated glomerular filtration rate (eGFR) than the NRVL group,and the eGFR of the TMA group was lower than that of the LV,AS,and ICD groups (all P<0.001).The renal pathological activity index (AI) of each renal vascular lesion group was higher than that of the NRVL group (all P<0.001),and the AI value of the TMA and LV groups was higher than that of the AS group (both P<0.001).There was no significant difference in AI value between TMA and LV groups (P=0.675),while the proportion of fibrinoid necrosis in the LV group was higher than that in the TMA group (P=0.012).The TMA group had the highest degree of chronicity and higher chronic index than the AS (P=0.021),LV (P<0.001),ICD (P<0.001),and NRVL (P<0.001) groups.The AS group had the secondary highest degree of chronicity and higher median chronic index than the NRVL group (P=0.004).The TMA group had the lowest 1-year clinical remission rate and the highest proportion of annual eGFR decline >5 mL/(min·1.73 m2).Both TMA and AS groups showed lower long-term renal survival rates than the NRVL group (P<0.001,P=0.023) respectively. Conclusions Intrarenal vascular lesions are strongly associated with clinical severity and prognosis in LN.LV correlates with acute kidney injury and severe active renal injury,while TMA is the most severe subtype and characterized by high pathological activity,chronicity,poor treatment response,and adverse outcomes.AS,the most common type,does not affect treatment response but predicts unfavorable long-term renal survival. 目的 探讨狼疮性肾炎(LN)不同类型血管病变与患者临床、病理及预后的关系。方法 回顾性分析我院10年间LN患者的临床病理数据,探究不同血管病变与临床病理间的关系及多个角度分析肾血管病变对肾脏预后的影响。结果 共纳入644例LN患者,女性占82.6%,LN Ⅳ/Ⅳ+Ⅴ型占60.4%。根据血管病变类型分为4组:肾小动脉硬化(AS)组171例(26.6%)、血栓性微血管病(TMA)组78例(12.1%)、单纯免疫复合物沉积(ICD)组29例(4.5%)及狼疮血管病(LV)组19例(3.0%),无血管病变(NRVL)组347例(53.9%)作为对照。AS组患者平均年龄显著高于其他各组(P均<0.001)。与NRVL及AS组相比,TMA(P=0.009,P=0.025)和LV组(P=0.007,P=0.005)补体C3水平均显著降低、系统性红斑狼疮疾病活动指数及急性肾损伤的发生率均显著增加(P均<0.001)。除ICD组外,TMA(P<0.001)、LV(P<0.001)和AS组(P=0.037)估算的肾小球滤过率(eGFR)均显著低于NRVL组,其中TMA组的eGFR均显著低于LV、AS和ICD组(P均<0.001)。各肾血管病变组肾脏病理活动指数(AI)均显著高于NRVL组(P均<0.001),TMA和LV组AI值均显著高于AS组(P均<0.001)。TMA与LV组比较,AI值差异无统计学意义(P=0.675),但LV组纤维素样坏死比例显著高于TMA组(P=0.012)。慢性化程度TMA组最高,慢性指数显著高于AS(P=0.021)、LV(P<0.001)、ICD(P<0.001)和NRVL组(P<0.001);其次为AS组,中位慢性指数显著高于NRVL组(P=0.004)。TMA组1年内临床缓解率最低,年eGFR下降>5 mL/(min·1.73 m2)的比例最高。经长期随访,TMA和AS组患者肾脏存活率均显著低于NRVL组(P<0.001,P=0.023)。结论 肾内血管病变与LN临床和预后密切相关。LV与急性肾损伤的发生及严重活动性肾损伤相关;TMA最严重,存在较高的肾脏病理活动性和慢性病变,治疗反应相对较差,预后不佳;AS最常见,其存在不影响治疗反应,但与长期肾脏不良预后相关。.
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