The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
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Treatment outcomes and predictors in patients with idiopathic membranous nephropathy

특발성 막성 신병증 환자의 치료 결과 및 예후인자 분석

Shin, Hyun-Phil;Lee, Sang-Ho;Lee, Tae-Won;Kim, Myung-Jae;Ihm, Chun-Gyoo
신현필;이상호;이태원;김명재;임천규

  • Published : 20040000
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Abstract

Background : Idiopathic membranous nephropathy (IMN) is the most common cause of nephrotic syndrome in adults but the treatment regimen and the prognosis of IMN are controversial issue. Immunosuppresive treatment was preferably used in patients with high risk factors related to renal failure. We studied biopsy-proven idiopathic membranous nephropathy to evaluate clinical predictors for risk stratification and treatment outcomes according to regimens. Methods : 66 patients (51 male, 15 female) with biopsy-proven IMN at our hospital during the period of 1991 to 2001 were studied retrospectively. Clinical information and data were obtained at the time of presentation and followed up regularly. We used several different treatment regimen according to patients compliance, clinical and laboratory data. Seven patients were treated with conservative management, 12 with oral steroid alone, 47 with oral steroids and combination with oral cyclophosphamide (1-2 mg/kg/day for 6-12 months). The mean follow-up period was 53.4$\pm$34.2 month. Treatment oucomes and predictors were idetified. Results : At presentation, mean age was 45.5$\pm$14.7 years old and patients with nephrotic syndrome was 77.8%. Pathologic stages II (Ehrenreich and Churg classification) was most common (68.2%). After each treatment, 33.3% of the group treated with oral steroid alone showed partial remission (PR) and 33.3% showed complete remission (CR), in combination thrapy group (cyclophosphamide with steroids) 23.4% PR and 38.3% CR. During follow-up period, four patients (6.1%) developed into chronic renal insufficiency. We used multivariate analysis of prognostic factor associated with persistent CR and progression to chronic renal insufficiency (CRI). Initial response within one year after therapy and non smoking were predictior of persistnet CR and increased initial serum creatinine and old age was related to progression to CRI. Conclusion : At the end of follow-up, immunosuppresive therapy including oral cyclophosphamide and steroids induced favorable effect and can be used for high risk patients.

목적 : 논란이 있어왔던 특발성 막성 신병증의 치료에서 cyclophosphamide 병합요법의 치료효과를 알아보기위해 치료방법에 따른 결과를 보고, 각 치료법이 단백뇨의 관해와 만성 신부전 진행에 미치는 예후인자를 알아서 적절한 치료군을 설정하고 그 치료방법의 결정에 도움을 얻고자 후향적 연구를 시행하였다. 방법 : 경피적 신생검 후, 막성 신병증을 진단받은 환자 중 이차적 원인에 의한 경우를 제외한 66명(남자 51명, 여자 15명)의 환자를 관찰대상으로 하여 환자의 임상 및 검사 결과와 순응도에 따라 보존적 치료군과 경구 스테로이드 단독 요법군 그리고 경구 스테로이드-cyclophophamide 병합 요법군으로 나누어 경구 스테로이드 단독요법시는 0.5-1 mg/kg/day로 시작한 뒤 치료 반응에 따라 그 용량을 조절하였고, 병합 요법군에서는 경구 스테로이드에 cyclophophamide를 1-2 mg/kg/day로 병합하여 6-12개월 동안 사용하여 전체 및 각군의 치료성적을 알아보고 단백뇨의 관해와 만성 신부전으로의 진행에 관계되는 예후인자를 다변량 분석을 통하여 검정하였다. 결과 : 치료 방법에 따라 스테로이드 치료군은 전체 12예 중에 완전관해 4예(33.3%), 부분관해 4예(33.3%),무반응 4예(33.3%)를 보였고, cyclophosphamide와 스테로이드 병합 요법군은 완전관해 18예(38.3%), 부분관해11예(23.4%), 무반응 18예(38.3%)를 보여 치료방법에 따른 관해율의 차이는 나타나지 않았다. 평균 53,4개월의 추적관찰하였고, 예후인자를 다변량 분석한 결과 완전관해 유지는 1년 이내의 최초 치료에 반응이 있고, 비흡연군에서 높았으며 해당 환자수가 적었으나 만성 신부전으로의 진행은 내원시 혈청 reatinine 1.2 mg/dL 이상인 경우와 60세 이상의 고령군에서 많이 증가하는 것으로 나타났다. 결론 : 특발성 막성 신병증 환자에 있어 기존의 스테로이드 요법에 cyclophosphamide의 병용 여부에 따른 치료의 결과가 병합요법군에서 스테로이드 단독 요법과 대등한 완전 관해율을 보여 향후 cyclophosphamide와 스테로이드 병합요법이 특발성 막성 신병증, 특히 고위험군환자에서 적극적 치료 요법의 하나로 고려되어야 할 것이다.

Keywords

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