狼疮治疗经验循证广州

1、 赵岩北京协和医院风湿免疫科治疗：从经历到循证Expert Rev Clin Pharmacol. ;4(4):437-451 4g/dExpert Rev Clin Pharmacol. ;4(4):437-451 狼疮的诱导缓解治疗目的治疗(T2T)：缓解或部分缓解Ann Rheum Dis ;71:7 Expert Rev Clin Pharmacol. ;4(4):437-451 对经典LN的诱导缓解方案形成挑战Forest plot结果：MMF在诱导LN缓解方面较CTX更有效 PMichael Walsh. Mycophenolate Mofetil for Induction Th

2、erapy of Lupus Nephritis: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol. 2007;2:968-75Expert Rev Clin Pharmacol. ;4(4):437-451 诱导缓解华人首选：MMF 2g/d次选: Tac、NIH、Euro-lupusGood response (complete/good partial)Suboptimal response or no response (refractory)Maintenance therapyMMF 1-2g/dAZA 2g

3、/d3rd choice: CSA 2-3mg/dFor at least 36 monthsConsider re-BxRescue therapySteroid pulsesMMF 3g/dMMF 2g/d + Tac 4mg/dOral CYC 2mg/kg/dIV pulse CYCRituximabEpratuzumabBelimumabContreras et al. NEJM 2004; Moroni et al. CJASN 2006Houssiau et al. Ann Rheum Dis ; Wolfy et al. Vancouver meeting N=59Mainly

4、 Hispanics &Africans78% class IV disease64% nephrotic IV pulse CYC for 4-7 pulses (0.5-1g/m2) MMF AZA (1-3mg/kg/day)Quarterly pulseCYCComposite outcome of death and ESRDRenal flareMMF = AZA均好于静脉CYCAnn Rheum Dis ;71(Suppl3):540 Expert Rev Clin Pharmacol. ;4(4):437-451 LMN (活检证实) V + III / V + IV细

5、微： ACEI / ARB pred中重度：ACEI / ARB + Pred + AZA严重/ 难治性：ACEI / ARB + Pred + MMF / CSA / Tac / CYC / MMF + Tac / 实验性治疗如：sirolimus, infliximab, rituximabTreat as proliferative LN Pure VANA+1:3200,dsDNA26%,C3,c-ANCA病理诊断：III(A)LN,血栓性微血管病TMA 恶性高血压肾活检激素+CTXHD卡托普利ARB CCB临床概念TTPHUSTMA病理概念小动脉血栓内膜水肿、内皮 肿胀增宽血管壁纤维

6、素样坏死 研究背景结果-临床LN伴TMA存在2种机制？富免疫沉积型TMA免疫因素寡免疫沉积型TMA直接的血管内皮损伤机制决定治疗反响：富免疫型TMA免疫因素较多对激素+免疫抑制剂反响较好寡免疫型TMA免疫因素较少对激素+免疫抑制剂反响较差GFR蛋白尿醛固酮释放肾小球硬化Adapted from Willenheimer R et al. Eur Heart J. 1999;20:9971008; Dahlf B. J Hum Hypertens. 1995;9(suppl 5): S37S44; Daugherty A et al. J Clin Invest. 2000;105:160516

7、12; Fyhrquist F et al. J Hum Hypertens. 1995;9(suppl 5): S19S24; Booz GW, Baker KM. Heart Fail Rev. 1998;3:125130; Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999: 16821704; Anderson S. Exp Nephrol. 1996;4(suppl 1):3440; Fogo AB. Am J Kidney Dis. 2000;35:179188.AII AT1 receptor动脉粥样硬化血管收缩血管增生内皮功能紊乱左心室肥厚纤维化重构细胞凋亡卒中高血压心肌梗死心衰肾衰RAS与心肾事件链的关系RAS激活危险因素：高血压、糖尿病、高血脂内皮功能紊乱微血管病变动脉粥样硬化、左室肥大冠心