Med. J. Kagoshima Univ., July, 2015 成人紫斑病性腎炎に対するステロイド療法の検討 阿部正治, 猪俣美穂, 吉嶺陽仁, 古城卓真, 村岡良朗, 吉嶺陽造, 小山田美紀, 福元まゆみ, 屋万栄, 徳永公紀, 野﨑剛, 井戸章雄 鹿児島大学大学院医歯学総合
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1 成人紫斑病性腎炎に対するステロイド療法の検討 阿部正治, 猪俣美穂, 吉嶺陽仁, 古城卓真, 村岡良朗, 吉嶺陽造, 小山田美紀, 福元まゆみ, 屋万栄, 徳永公紀, 野﨑剛, 井戸章雄 鹿児島大学医学雑誌 2015 年 7 月
2 Med. J. Kagoshima Univ., July, 2015 成人紫斑病性腎炎に対するステロイド療法の検討 阿部正治, 猪俣美穂, 吉嶺陽仁, 古城卓真, 村岡良朗, 吉嶺陽造, 小山田美紀, 福元まゆみ, 屋万栄, 徳永公紀, 野﨑剛, 井戸章雄 鹿児島大学大学院医歯学総合研究科消化器疾患 生活習慣病学分野 連絡先阿部正治 鹿児島市桜ヶ丘 鹿児島大学大学院歯学総合研究科消化器疾患 生活習慣病学分野電話 : / FAX : Effectiveness of Steroid Therapy for Henoch-Schönlein Purpura Nephritis Masaharu Abe, Miho Inomata, Haruhito Yoshimine, Takuma Kojou, Yoshiro Muraoka, Yozo Yoshimine, Miki Oyamada, Mayumi Fukumoto, Manei Oku, Koki Tokunaga, Tsuyoshi Nosaki, Akio Ido Department of Digestive and Life-style Diseases Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka Kagoshima Japan (Received Apr. 14; Revised May. 19; Accepted Jun. 15) Address to correspondence Masaharu Abe Department of Digestive and Life-style Diseases Kagoshima University Graduate School of Medical and Dental Sciences Sakuragaoka Kagoshima Japan Phone: FAX: Abstract Purpose: Steroid therapy has been established for pediatric patients with Henoch-Schönlein purpura nephritis (HSPN). Therefore, adult patients with HSPN have been treated with steroid alone or combined with tonsillectomy. However the effect of steroid therapy with or without tonsillectomy in adult patients remains to be determined. This study aims to evaluate whether steroid therapy with or without tonsillectomy affects the clinical course of adult HSPN patients. Methods: We retrospectively investigated nine adult patients, including five men, with biopsy-proven HSPN from 2006 to 2012, followed by observation for more than 12 months (range: 19 to 97 months). Results: The median age of the patients was 36 years (range 20 to 72) at the time of renal biopsy. Three patients received steroid pulse therapy combined with tonsillectomy, and three received steroid therapy. In three additional patients, one was treated with an angiotensin II receptor blocker (ARB) and dilazep, one was treated with a Ca blocker, and the other did not receive any medication. Except for the patient receiving the Ca blocker, eight patients were in remission throughout the observation period. Notably, two of
3 28 three patients treated with steroid pulse therapy and tonsillectomy and one of three with steroid exhibited a rapid decrease in urinary excretion of protein, resulting in remission within a year. Conclusions: All patients receiving steroid therapy with or without tonsillectomy were in remission. These results suggest that steroid therapy alone, regardless of tonsillectomy, is likely effective in adult patients with HSPN. Key words: Henoch-Schönlein purpura nephritis, tonsillectomy, steroid (Henoch-Schönlein purpura nephritis HSPN) IgA Henoch-Schönlein (HSP) HSP HSPN HSPN 2) 3) HSPN ) 3 ( (ARB) ) ( RBC 5 /High Power Field ) ( 0.3g/gCr ) egfr Cr GFR 194 Cr ( 0.739) Table1. Basic characteristics of the patients 全体 (n = 9) 年齢, 中央値 ( 範囲 ) 36.0(20-72) 性別 ( 男 / 女 ) 5/4 BUN * (mg/dl) 14.3±5.9 Cr * (mg/dl) 0.78±0.31 egfr * (ml/min/1.73m2) 86.7±28.8 IgA * (mg/dl) 453±412 C3 * (mg/dl) 101.5±13.2 CRP * (mg/dl) 1.7±2.8 ASO * (IU/mL) 111.5±130.4 U-TP * (g/gcr) 3.49±4.25 Complication Purpura 9 Nephrotic syndrome 3 Arthralgia 4 Abdominal pain 3 ISKDC Grade(Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ) 1,3,5,0,0 * Values are expressed as mean±sd.u-tp:proteinuria
4 29 ( )36 (20-72 ) 5 Cr mg/dL egfr mL/min/1.73m g/gCr (Table1.2) 3 (33.3 ) 1 4 (44.4%) 4 (44.4%) 1 International Study of Kidney Disease in Childhood (ISKDC) grade 1 grade 3 grade 5 2 HBV Cyclosporin A(CyA) 3 (ISKDC grade ) (ISKDC grade ) (ISKDC grade ) ARB Ca 3 9 HSPN HBV IgA CRP ISKDC grade g/gCr 6 ( 3 3 ) 3 Cr egfr (Fig.1) 1 5 Ca 1 1 Cr 1 CyA 2 Cr egfr egfr (Table3) mg/kg Table2. Characteristics of patients at baseline ステロイド群 保存的加療群 (n = 6) (n = 3) 年齢 45.8± ±26.6 性別 ( 男 / 女 ) 3/3 2/1 BUN(mg/dL) 14.3± ±2.49 Cr(mg/dL) 0.80± ±0.30 egfr(ml/min/1.73m2) 83.9± ±32.6 IgA(mg/dL) 515.0± ±45.0 C3(mg/dL) 102.2± ±21.8 CRP(mg/dL) 2.38± ±0.32 ASO(IU/mL) 82.4± ±188.8 U-TP(g/gCr) 5.0± ±0.19 ISKDC Grade(Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ) 0, 2, 4, 0, 0 1, 1, 1, 0, 0 Values are expressed as mean±sd.
5 過観察 30 3 Ca 1 ARB HSP ) (100%) ) HSPN ) 33.3 HSPN 6) IgA HSPN 2) 3) HSPN IgA IgA 7) IgA 2) ISKDC grade HSPN 8) HBV ISKDC grade CyA ISKDC grade 4 Table3. Histopathological and laboratory data of all patients 年齢性別治療前 1 年後治療前 1 年後潜血蛋白ステロイド療法ISKDC Grade 治療 血清 Cr(mg/dL) 尿蛋白 (g/gcr) 陰性化に要した期間 ( 月 ) 35 F Ⅲ 群64 M Ⅲ ステロイド内服 扁桃摘出 M Ⅱ ステロイド F Ⅲ パルス 陰性 F Ⅱ ステロイドパルス 経ステロイド 70 M Ⅲ 内服 + CyA ARB ジラゼプ塩酸塩 20 F Ⅲ なし M Ⅰ Ca 拮抗薬 未寛解 未寛解 群36 M Ⅱ
6 31 IgA 9) HSPN 1g/ ( Cr ) 10) 11) 12) HSPN HSPN ) Cr 7) 10) 8 1 HSPN HSPN9 HSPN : 1) Hass M IgA nephropathy and Henoch-Schönlein purpura nephritis Pathology of the Kidney Jennette JC Olson JL Schwartz MM Silva FG 6th ed Lippincott Williams Wilkins Philadelphia 2007 p424 2) ) Sugiyama H Watanabe N Onoda T Kikumoto Y Yamamoto M Maeta M et al. Successful treatment of progressive Henoch-Schönlein purpura nephritis with tonsillectomy and steroid pulse therapy Intern Med 2005 Fig.1 Changes of Urine protein, serum Cr and egfr from day before therapy to 12-month follow-up Because one case that was urine protein negative did not enforce an examination for fixed-quantity one year later, I transcribe it in urine protein 0 mg/dl.
7 ) Saulsbury FT Henoch-Schönlein purpura in children Report of 100 patients and review of the literature Medicine(Baltimore) ) (Schönlein-Henoch ) Frontiers in Gastroenterology ) Shin JI Park JM Shin YH Kim JH Lee JS Jeong HJ Henoch-Schönlein purpura nephritis with cyclosporin A and steroid treatment Scand J Rheumatol ) Lau KK Suzuki H Jan Novak Wyatt RJ Pathogenesis of Henoch-Schönlein purpura nephritis Pediatr Nephrol ) ) IgA ) Coppo R Andrulli S Amore A Gianoglio B Conti G Peruzzi L Predictors of outcome in Henoch-Schönlein nephritis in children and adults Am J Kidney Dis ) ) ) Pillebout E Thervet E Hill G Alberti C Vanhille P Nochy D Henoch-Schönlein purpura in adults outcome and prognostic factors J Am Soc Nephrol
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