急性感染后新月体肾炎

--感染后新月体肾炎急性感染后肾小球肾炎主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究本例临床特点：上呼吸道感染后（4～5天）肉眼血尿，大量蛋白尿，浮肿ASO逐渐下降C3逐渐回升

血肌酐升高，在无特殊治疗情况下已逐渐下降9.169.239.269.2810.210.610.710.1310.1810.2010.25C3g/L0.410.710.670.660.520.620.62ASO（IU/mL）3752702521429690SCr（umol/L）3733122301881971391631671659.27MP冲击急性感染后肾小球肾炎临床诊断：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甲强龙冲击为什么不诊断为急进性肾炎患者在用激素冲击前肾功能已好转，而不是进行性恶化。因此我认为临床上不符合急进性肾炎。急进性肾炎为急性快速进展性肾小球肾炎（acuterapidlyprogressiveglomerulonephritis，ARPG）的简称。它起病急骤，可在数日、数周或数月内肾功能急剧恶化，以少尿（无尿）性急性肾功能衰竭为多见。急性肾炎综合征进行性肾功能损害。新月体性肾炎ARPG特征：临床：病理：肾小球弥漫性毛细血管内中重度增生伴毛细血管腔闭塞及多核白细胞滞留－－典型APGN病理

26个肾小球，7个球性硬化，11个肾小球见大型细胞性新月体。（IF）以IgA及C3沉积最强，呈颗粒状，肾小球毛细血管壁及系膜区分布为主。病理特点结合临床病理，可诊断：感染后新月体肾炎。新月体肾炎急进性肾炎感染后新月体肾炎比较少见（占肾活检标本4.6％）相比而言，老年人易出现感染细菌：链球菌，金黄色葡萄球菌，革兰氏阴性杆菌等。Anupdateonacutepostinfectiousglomerulonephritisworldwide.Kanjanabuch,T.etal.Nat.Rev.Nephrol.5,259–269(2009)感染后肾炎绝大部分未行肾活检活检时机和指征不一样，新月体比例也不一样因此，确切的发病率无法统计和报道主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究Pediatrics1975新月体肾炎例数链感后随访预后171018to57months链感后预后较好TheJournalofPediatrics1981链感后新月体肾炎pre+ctx/aza支持治疗预后10例（Ccr<30)5例5例两组预后无显著差别KI1985新月体肾炎例数链球菌感染后低补体血症预后50（平均GFR42)占34％占48％链感后新月体肾炎呈自限性，预后较好AmJofnephrology1992largecrescentsinmorethan50%oftheglomeruli链感后新月体肾炎急进性肾炎/非ARPG预后43例1131/1223CRF,14CRI,6recover;11APSGN中，7CRF,2CRI,2recover。急性链感后肾炎新月体多于50%预后(随访1－8年)新月体少于50％预后(随访1.3－5年)2711（临床ARPGN7例）2ESRD16（3ARF,10无新月体)6例失访4st＋ctx9recover1st＋ctx无ESRD5st4st8Dialysis8Dialysis不确定激素治疗能获益PediatrNephrol(2009)主要内容讨论病例临床诊断的个人观点儿童感染后新月体肾炎的相关文献报道成人感染后肾炎的病例报道和临床研究杂志例数病菌临床病理预后Nephron20028MRSA潜伏期4-16w,5例ARF,7例伴新月体，2例新月体>50%;IF:IgA,C3.抗感染后4例好转，1HD,2例用激素后感染再发死亡KidneyInt.

1995Jan;4710MASRabruptorinsidiousonsetofRPGN1例proliferativeGN伴新月体，4例未活检2HD,1CRF,5CRI,2恢复Clin

Nephrol.

1997,481MASAproteinuriaandrenaldysfunctionminortomildMsPGNHUMANPATHOLOGY2003,345葡萄球菌ARF(基础病2-DM，DN)IF:IgA，

C3为主，未提及新月体4例HD,1例部分恢复HumanPathology(2008)3913葡萄球菌ARIIF:IgA，

C4为主，未提及新月体4例有基础CRI进入ESRD,7例肾功能好转Long‐termprognosisofdiffuseproliferativeglomerulonephritisassociatedwithinfectioninadults

GabriellaMoroni1,ClaudioPozzi2,SilvanaQuaglini3,

Nephrol.Dial.Transplant.-2002病例入选标准：临床生化和病理标准至少各2条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(绿脓杆菌2patients),

Haemophilusinfluenzae(嗜血杆菌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地中海贫血，1肌炎，1磷脂抗体综合征。MainfindingsatrenalbiopsyGroup1Group2P

Total(%)Lightmicroscopy(numberofpatients)292150(100)

Endocapillaryproliferation291848(96)

Membranoproliferative

0

2

2(4)

Crescentsin>30%ofglomeruli

7110.0718(36)

Glomerular

fibrinoidnecrosis

4

4n.s.

8(16)

Interstitialinfiltration(2+or3+)

816<0.0118(36)

Vascularfibrinoidnecrosis

1

2n.s.

3(6)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

9Renalinsufficiency(n)

3(11%)

9(43%)

13(27%)

Follow‐up(months)

46,175,18036(9–48)

46(12–110)

Plasmacreatinine(mg/dl)

1.5,1.9,2.4

2(1.7–2.4)

1.9(1.7–2.4)

Proteinuria(g/24 h)

0.5,0.9,2.4

1(0.5–1.5)

1(0.5–2)

Microscopichaematuria(n)

210

12dialysis(numberofpatients)

2(7%)

3(14%)

5(10%)

Follow‐up(months)

1,3

2,2,6

2(2–3)Remission(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:univariateanalysisAtmultivariateanalysisonlytheabsenceofanunderlyingdisease,(P=0.04)andtheabsenceofinterstit