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1、-感染后新月体肾炎,温州医学院附属第一医院 陈天新,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（45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,9.27MP冲击,急性感染后肾小球肾炎,临床诊断：,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
2、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（acute rapidly progressive glomerulonephritis，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
3、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。,An update on acute postinfectious glomerulonephritis worldwide. Kanjanabuch, T. et al. Nat. Rev. Nephrol. 5, 259269 (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
4、肾炎的病例报道和临床研究,不确定激素治疗能获益,Pediatr Nephrol (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,Longterm prognosis of diffuse proliferative glomerulonephritis associated with infection in adults,Gabriella Moroni 1 , Claudio Pozzi 2 , Silvana Quaglini 3 ,Nephrol. Dial. Transplant.-2002,病例入选标准：临
5、床生化和病理标准至少各2条,Clinical/biochemical criteria included (i) a recent episode of infection, (ii) antistreptolysin O titre 250 IU/l (iii) a transient reduction of serum complement fractions.Histological criteria included (i) diffuse proliferative and/or exudative glomerulonephritis, (ii) dominant granula
6、r immunedeposits of IgG and/or C3 in the subepithelial position at immunofluorescence (cases with faint deposits of IgA were included according to Silva 7) (iii) presence of humps on electron microscopy.,Exclusion criteria were:,predominant IgA deposits on immunofluorescence; idiopathic membranoprol
7、iferative glomerulonephritis;cryoglobulinaemic nephritis; lupus nephritis.,The infective agents cultured from the sites of infection :,Streptococcus haemolyticus (5 patients),Staphylococcus aureus (6 patients), Escherichia coli (8 patients), Pseudomonas aeruginosa (绿脓杆菌2 patients), Haemophilus influ
8、enzae (嗜血杆菌1 patient). 21 of the 45 patients evaluated had high antistreptolysin titre.,Clinical characteristics of patients at presentation,Group 1： APIGN without other underlying disease (29 patients).,Group 2 :APIGN with severe underlying disease (21 patients), 9 liver cirrhosis, 4 malignant neop
9、lasia,5 DM（其中3例有肝硬化）, 3 COPD, 1 地中海贫血，1肌炎，1磷脂抗体综合征。,Main findings at renal biopsy,Renal status of 49 patients at the last observation,Clinical and histological predictors of complete remission: univariate analysis,At multivariate analysis only the absence of an underlying disease, (P=0.04) and the a
10、bsence of interstitial infiltration (P=0.036) were predictive of complete remission. The relative risk of incomplete recovery were 3.5 (95% CI, 1.0312.2) and 8.7 (95% CI, 1.1565.5).,this study shows that infectionassociated glomerulonephritis should be considered a serious disease in adults, particu
11、larly when there is a previous disease and/or when it is associated with severe interstitial infiltration at renal biopsy. Even in favorable cases recovery may require several months.Patients with incomplete recovery should be regularly monitored as many of them may progress to chronic renal insufficiency.The treatment with steroids did not improve the outcome; rather it was associated with a worse prognosis.,In conclusion,
