Kidney Int:糖皮质激素和环磷酰胺交替治疗原发性膜性肾病优于他克莫司和利妥昔单抗的序贯治疗

2021-09-06 从医路漫漫 MedSci原创

对于进展风险较高的原发性膜性肾病患者,推荐周期性使用糖皮质激素和环磷酰胺方案。

目的:对于进展风险较高的原发性膜性肾病患者,推荐周期性使用糖皮质激素和环磷酰胺方案。我们假设他克莫司和利妥昔单抗的序贯治疗优于糖皮质激素和环磷酰胺的周期性交替治疗,以诱导这些患者持续缓解。

方法:这是随机对照研究,对86例原发性膜性肾病和持续性肾病综合症患者进行6个月观察,各组分配43例患者接受糖皮质激素和环磷酰胺6个月的周期性治疗或他克莫司的序贯治疗(全剂量6个月,逐渐减量3个月)和利妥昔单抗(第6个月1g)。主要结果是24个月时肾病综合征完全或部分缓解。糖皮质激素-环磷酰胺组中有36例(83.7%)患者出现综合结局,他克莫司-利妥昔单抗组中有25例(58.1%)患者出现综合结局(相对风险1.44;95%置信区间1.08 - 1.92)。糖皮质激素-环磷酰胺组26例(60%)完全缓解,他克莫司-利妥昔单抗组11例(26%)(2.36;1.34至4.16)。两组的抗PLA2R滴度均显着下降,但糖皮质激素-环磷酰胺组在3个月和6个月时达到免疫应答(抗PLA2R抗体耗尽)的抗PLA2R阳性患者的比例与他克莫司-利妥昔单抗组相比(分别为45%和70%),在3个月和6个月显著升高(分别为77%和92%)。糖皮质激素-环磷酰胺组1例复发,他克莫司-利妥昔单抗组3例复发。两组严重不良事件相似。

表1 3至24个月完全或部分缓解的综合结局;意向治疗分析包括所有接受随机分组的患者,而按方案分析包括所有接受试验药物治疗的患者。

在这两项分析中,主要结果是24个月时完全或部分缓解;数据为n(%)或95% CI;CI,置信区间。

 

表2 3至24个月完全缓解;意向治疗分析包括所有接受随机分组的患者,而按方案分析包括所有接受试验药物治疗的患者。

在这两项分析中,主要结果是24个月时完全或部分缓解;数据为n(%)或95% CI;CI,置信区间

 

图1 完全或部分缓解的Kaplan-Meier分析。Kaplan-Meier估计糖皮质激素-环磷酰胺和

他克莫司-利妥昔单抗组(a)缓解(完全或部分)和(b)完全缓解。

 

图2 蛋白尿和抗磷脂酶A2受体(PLA2R)、血清白蛋白和估计肾小球滤过率(eGFR)的进化。

数据以中位数(四分位数范围)表示(白蛋白、蛋白尿、抗PLA2R)或平均值±SD表示。

 

表3 不同治疗组抗PLA2R抗体的进化及免疫应答百分比;IQR,,四分位间距;PLA2R:磷脂酶A2受体;

RU,相对单位。中位数的差异与Mann-Whitney检验进行比较

结论:糖皮质激素-环磷酰胺治疗原发性膜性肾病诱导缓解的患者数量明显多于他克莫司-利妥昔单抗因此认为糖皮质激素和环磷酰胺交替治疗原发性膜性肾病优于他克莫司和利妥昔单抗序贯治疗。

原文出处

  Fernández-Juárez G,  Rojas-Rivera J,et al,The STARMEN trial indicates that alternating treatment with corticosteroids and cyclophosphamide is superior to sequential treatment with tacrolimus and rituximab in primary membranous nephropathy.Kidney Int 2021 04;99(4) 

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target=_blank style='color:#2F92EE;'>#他克莫司#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=25321, encryptionId=fbd825321ba, topicName=他克莫司)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9d0b2500136, createdName=12498b08m90暂无昵称, createdTime=Wed Sep 08 08:37:47 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1600439, encodeId=e203160043954, content=<a href='/topic/show?id=3565e21649e' target=_blank style='color:#2F92EE;'>#皮质激素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=72164, encryptionId=3565e21649e, topicName=皮质激素)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cb1a18781011, createdName=bbwznl, createdTime=Wed Sep 08 08:37:47 CST 2021, time=2021-09-08, status=1, ipAttribution=), 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    2021-12-01 nahsey

    学习了

    0

  4. 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  5. 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    2021-11-11 ms4000001945859757

    学习啦

    0

  6. 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target=_blank style='color:#2F92EE;'>#他克莫司#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=25321, encryptionId=fbd825321ba, topicName=他克莫司)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9d0b2500136, createdName=12498b08m90暂无昵称, createdTime=Wed Sep 08 08:37:47 CST 2021, time=2021-09-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1600439, encodeId=e203160043954, content=<a href='/topic/show?id=3565e21649e' target=_blank style='color:#2F92EE;'>#皮质激素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=72164, encryptionId=3565e21649e, topicName=皮质激素)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cb1a18781011, createdName=bbwznl, createdTime=Wed Sep 08 08:37:47 CST 2021, time=2021-09-08, status=1, ipAttribution=), 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  7. 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    2021-09-08 zhouqu_8

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