-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人觀點兒童感染后新月體腎炎的相關(guān)文獻報道成人感染后腎炎的病例報道和臨床研究,主要內(nèi)容,討論病例臨床診斷的個人觀點兒童感染后新月體腎炎的相關(guān)文獻報道成人感染后腎炎的病例報道和臨床研究,本例臨床特點：,上呼吸道感染后（45天）肉眼血尿，大量蛋白尿，浮腫ASO逐漸下降C3逐漸回升血肌酐升高，在無特殊治療情況下已逐漸下降,9.27MP沖擊,急性感染后腎小球腎炎,臨床診斷：,9.27甲強龍沖擊,為什么不診斷為急進性腎炎,患者在用激素沖擊前腎功能已好轉(zhuǎn)，而不是進行性惡化。因此我認為臨床上不符合急進性腎炎。,急進性腎炎為急性快速進展性腎小球腎炎（acuterapidlyprogressiveglomerulonephritis，ARPG）的簡稱。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（無尿）性急性腎功能衰竭為多見。,急性腎炎綜合征,進行性腎功能損害。,新月體性腎炎,ARPG特征：,臨床：,病理：,腎小球彌漫性毛細血管內(nèi)中重度增生伴毛細血管腔閉塞及多核白細胞滯留典型APGN病理26個腎小球，7個球性硬化，11個腎小球見大型細胞性新月體。（IF）以IgA及C3沉積最強，呈顆粒狀，腎小球毛細血管壁及系膜區(qū)分布為主。,病理特點,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.5,259269(2009),感染后腎炎絕大部分未行腎活檢活檢時機和指征不一樣，新月體比例也不一樣因此，確切的發(fā)病率無法統(tǒng)計和報道,主要內(nèi)容,討論病例臨床診斷的個人觀點兒童感染后新月體腎炎的相關(guān)文獻報道成人感染后腎炎的病例報道和臨床研究,不確定激素治療能獲益,PediatrNephrol(2009),主要內(nèi)容,討論病例臨床診斷的個人觀點兒童感染后新月體腎炎的相關(guān)文獻報道成人感染后腎炎的病例報道和臨床研究,Longtermprognosisofdiffuseproliferativeglomerulonephritisassociatedwithinfectioninadults,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)antistreptolysinOtitre250IU/l(iii)atransientreductionofserumcomplementfractions.Histologicalcriteriaincluded(i)diffuseproliferativeand/orexudativeglomerulonephritis,(ii)dominantgranularimmunedepositsofIgGand/orC3inthesubepithelialpositionatimmunofluorescence(caseswithfaintdepositsofIgAwereincludedaccordingtoSilva7)(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.,Clinicalcharacteristicsofpatientsatpresentation,Group1：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。,Mainfindingsatrenalbiopsy,Renalstatusof49patientsatthelastobservation,Clinicalandhistologicalpredictorsofcompleteremission:univariateanalysis,Atmultivariateanalysisonlytheabsenceofanunderlyingdisease,(P=0.04)andtheabsenceofinterstitialinfiltration(P=0.036)werepredictiveofcompleteremission.Therelativeriskofincompleterecoverywere3.5(95%CI,1.0312.2)and8.7(95%CI,1.1565.5).,thisstudyshowsthatinfectionassociatedglomerulonephritisshouldbeconsideredaseriousdiseaseinadults,particularlywhenthereisapreviousdiseaseand/orwhenitisassociatedwithsevereinterstitialinfiltrationatrenalbiopsy.Eveninfavorablecasesrecoverymayrequireseveralmonths.Patientswithincompleterecoveryshouldberegularlymonitored