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微小病变性肾病及其他类型肾病综合征中的急性肾损伤

Author
Alain Meyrier, MD
Section Editors
Richard J Glassock, MD, MACP
Fernando C Fervenza, MD, PhD
Deputy Editor
John P Forman, MD, MSc
Translators
郑红光, 主任医师，教授

引言

尽管微小病变肾病患者在就诊时光镜下肾小球表现相对正常，但许多成人和儿童患者出现肾小球滤过率(glomerular filtration rate, GFR)轻度下降(平均30%)，由血浆肌酐水平小幅上升所证实[1-4]。这种相对常见的变化可能至少部分是由本病特征性改变足突融合所致[2,3]。人们认为，已通过肾小球基底膜的滤过液通过毗邻的足突间裂隙进入肾小囊腔。足突融合减少了滤过裂隙频次(filtration slit frequency，通过每微米长度的肾小球基底膜上滤过裂隙的数目评估)，从而增加平均滤过路径长度[2,5]。

然而，一些微小病变病例(主要是成人)可出现GFR中度至重度下降急性发作，这时可能需要暂时透析治疗[1,4,6,7]：

●一项纳入95例微小病变成年患者的回顾性研究发现，18%的患者表现为急性肾损伤(acute kidney injury, AKI)，超过1/4的患者最终发生过一次AKI发作[7]。男性、年龄较大个体、以及伴有高血压、血清白蛋白水平较低及蛋白尿较为严重者，AKI的风险升高。

●一项纳入277例微小病变中国患者的回顾性研究发现，95例患者(34%)发生AKI[8]。AKI的重大危险因素包括：严重低白蛋白血症、年龄较大和男性性别。不管AKI严重程度如何，在3个月时超过90%的患者从AKI中恢复。

●另一项针对患肾病综合征但光镜下肾小球没有或仅有微小病变的患者的AKI的综述发现，85%的报道病例有微小病变性肾病，另有8%的患者似乎为特发性局灶节段性肾小球硬化[4]。在膜性肾病患者中，则很少报道AKI[9]。

           

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Literature review current through: 2017-06 . | This topic last updated: 2016-10-19.
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References
Top
  1. Nolasco F, Cameron JS, Heywood EF, et al. Adult-onset minimal change nephrotic syndrome: a long-term follow-up. Kidney Int 1986; 29:1215.
  2. Drumond MC, Kristal B, Myers BD, Deen WM. Structural basis for reduced glomerular filtration capacity in nephrotic humans. J Clin Invest 1994; 94:1187.
  3. Bohman SO, Jaremko G, Bohlin AB, Berg U. Foot process fusion and glomerular filtration rate in minimal change nephrotic syndrome. Kidney Int 1984; 25:696.
  4. Smith JD, Hayslett JP. Reversible renal failure in the nephrotic syndrome. Am J Kidney Dis 1992; 19:201.
  5. Deen WM. What determines glomerular capillary permeability? J Clin Invest 2004; 114:1412.
  6. Jennette JC, Falk RJ. Adult minimal change glomerulopathy with acute renal failure. Am J Kidney Dis 1990; 16:432.
  7. Waldman M, Crew RJ, Valeri A, et al. Adult minimal-change disease: clinical characteristics, treatment, and outcomes. Clin J Am Soc Nephrol 2007; 2:445.
  8. Chen T, Lv Y, Lin F, Zhu J. Acute kidney injury in adult idiopathic nephrotic syndrome. Ren Fail 2011; 33:144.
  9. Kunis CL, D'Agati V, Appel GB. Acute renal failure (ARF) in idiopathic nephrotic syndrome (NS) (abstract). J Am Soc Nephrol 1997; 8:126A.
  10. Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001; 60:804.
  11. Koomans HA. Pathophysiology of acute renal failure in idiopatic nephrotic syndrome. Nephrol Dial Transplant 2001; 16:221.
  12. Haas M, Spargo BH, Wit EJ, Meehan SM. Etiologies and outcome of acute renal insufficiency in older adults: a renal biopsy study of 259 cases. Am J Kidney Dis 2000; 35:433.
  13. Moutzouris DA, Herlitz L, Appel GB, et al. Renal biopsy in the very elderly. Clin J Am Soc Nephrol 2009; 4:1073.
  14. Vande Walle J, Mauel R, Raes A, et al. ARF in children with minimal change nephrotic syndrome may be related to functional changes of the glomerular basal membrane. Am J Kidney Dis 2004; 43:399.
  15. Cameron MA, Peri U, Rogers TE, Moe OW. Minimal change disease with acute renal failure: a case against the nephrosarca hypothesis. Nephrol Dial Transplant 2004; 19:2642.
  16. Chen CL, Fang HC, Chou KJ, et al. Increased endothelin 1 expression in adult-onset minimal change nephropathy with acute renal failure. Am J Kidney Dis 2005; 45:818.
  17. Lowenstein J, Schacht RG, Baldwin DS. Renal failure in minimal change nephrotic syndrome. Am J Med 1981; 70:227.
  18. Meltzer JI, Keim HJ, Laragh JH, et al. Nephrotic syndrome: vasoconstriction and hypervolemic types indicated by renin-sodium profiling. Ann Intern Med 1979; 91:688.
  19. Geers AB, Koomans HA, Roos JC, Dorhout Mees EJ. Preservation of blood volume during edema removal in nephrotic subjects. Kidney Int 1985; 28:652.
  20. Clive DM, Stoff JS. Renal syndromes associated with nonsteroidal antiinflammatory drugs. N Engl J Med 1984; 310:563.
  21. Almansori M, Kovithavongs T, Qarni MU. Cyclooxygenase-2 inhibitor-associated minimal-change disease. Clin Nephrol 2005; 63:381.
  22. Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med 2003; 348:491.
  23. Luyckx VA, Naicker S. Acute kidney injury associated with the use of traditional medicines. Nat Clin Pract Nephrol 2008; 4:664.
  24. Raij L, Keane WF, Leonard A, Shapiro FL. Irreversible acute renal failure in idiopathic nephrotic syndrome. Am J Med 1976; 61:207.
  25. Rennke HG, Klein PS. Pathogenesis and significance of nonprimary focal and segmental glomerulosclerosis. Am J Kidney Dis 1989; 13:443.