Ishod bolesnika s IgA-nefropatijom ovisno o modalitetu liječenja

Ines Bosnić Kovačić, Bojana Maksimović, Željka Jureković, Lada Zibar, Bojana Šimunov, Branislav Čingel, Snježana Šulc, Ivan Margeta, Ksenija Vučur Šimić, Danica Galešić Ljubanović, Petar Šenjug, Vanja Ivković, Mladen Knotek, Mario Laganović

Uvod: IgA-nefropatija (IgAN) ima varijabilnu prezentaciju i prognozu. Međunarodni alat za predviđanje rizika u IgAN-u (IgAN-PT, od engl. International IgA Nephropathy Prediction Tool) predviđa napredovanje bubrežne bolesti do završnog stupnja ili smanjenje procijenjene glomerulske filtracije (eGFR) za 50%. Preporučuje se optimalna suportivna terapija najmanje tri mjeseca, praćena šestomjesečnom primjenom glukokortikoida samo u bolesnika s velikim rizikom napredovanja. Cilj: Istražiti koji su bolesnici imali veću vjerojatnost primiti imunosupresivnu terapiju (IS) te ishode liječenih IS-om. Ispitanici i metode: Retrospektivno kohortno istraživanje 48 bolesnika (33 muškarca), medijana dobi 50 godina (interkvartilni raspon, IQR, od engl. interquartile range 35 – 59), medijana praćenja 43 mjeseca (IQR 18 – 54), liječenih u Kliničkoj bolnici Merkur s novodijagnosticiranim idiopatskim IgAN-om u razdoblju od 2012. do 2021. godine. Rezultati: Imunosupresiju je primilo 17 bolesnika i oni su češće imali mezangijsku (M) (82% prema 54%, p=0,05), endokapilarnu hipercelularnost (E) (65% prema 21%, p=0,004) i polumjesece (C) (41% prema 14%, p=0,04). U odnosu na one bez IS-a nije bilo značajne razlike u eGFR-u kod biopsije (52 (IQR 38 – 81) prema 46 (IQR 30 – 72) ml/min/1,73 m2, p<0,05), ali su liječeni IS-om imali veću eGFR nakon dvije godine praćenja (66 [IQR 37 – 97] prema 34 [IQR 20 – 56] ml/min/1,73 m2, p=0,02). Omjer proteina prema kreatininu u urinu (uPCR) smanjio se nakon liječenja (kod biopsije, 106 [IQR 50 – 317] prema završnom 47 [IQR 20 – 129] mg/mmol), a nije bilo razlike u početnom i završnom uPCR između onih koji jesu i nisu primali IS. Zbroj IIgAN se smanjio nakon liječenja (10,56% ± 12,66% prema 8,45% ± 9,22%, p=0,01), bez razlike u smanjenju između liječenih i neliječenih IS-om. Zaključci: Bolesnici s većim M, E i C su bili češće liječeni IS-om i oni su imali bolju eGFR nakon dvije godine; uPCR i zbroj IIgAN na kraju praćenja bili su manji neovisno o IS-u.

Introduction: IgA nephropathy (IgAN) exhibits variable clinical course and prognosis. To assess prognosis International IgAN Prediction (IgAN-PT) score was developed, and predicts the risk of a 50 % decline in estimated glomerular filtration rate (eGFR) or end-stage renal disease after biopsy. Only patients with a high risk of progression despite three months of optimized supportive care are considered for a six-month course of glucocorticoid therapy. Aim: of this study was to investigate which patients were more likely to receive immunosuppressive therapy (IS) and renal outcomes in patients treated with IS. Patients and methods: The retrospective cohort study included 48 patients (33 male), median age 50 years (interquartile range IQR 35–59), median follow-up 43 months (IQR 18–54), treated at Clinical Hospital Merkur for a newly diagnosed idiopathic IgAN from 2012 to 2021 Results: Seventeen patients were treated with IS. They had more frequently mesangial lesions (M) (82 % vs. 54 %, p=0.05), endocapillary hypercellularity (E) (65 % vs. 21 %, p=0.004) and crescents (C) (41 % vs. 14 %, p=0.04). There was no difference in eGFR at biopsy (52 (IQR 38–81) vs. 46 (IQR 30–72) mL/min/1.73 m2, p<0.05), but patients treated with IS had better eGFR after 2-year follow-up (66 (IQR 37–97) vs. 34 (IQR 20–56) mL/min/1.73 m2, p=0.02). Urinary protein to creatinine ratio (uPCR) decreased after the treatment (at biopsy vs. end of follow-up,
106 (IQR 50–317) vs. 47(IQR 20–129) mg/mmol)). Still, there was no difference in baseline or end of follow-up uPCR between patients receiving IS and not. IIgAN score decreased after the treatment (at biopsy vs. at 2-year follow- up (10.56 %±12.66 % vs. 8.45 %±9.22 %, p=0.01) without difference between those treated with IS and not. Conclusion: Patients with higher M, E and C score were more likely to be treated with IS, and had better eGFR after 2-year follow-up. uPCR and IIgAN score improved irrespective of the treatment modality.