探讨减量糖皮质激素联合优化支持治疗对肾移植术后IgA肾病(IgAN)患者肾功能和蛋白尿的影响。

回顾性分析2021年9月至2024年12月江西省人民医院36例经活检确诊为移植后IgAN患者资料，按是否采取减量糖皮质激素治疗方案，将其分为减量激素组(n＝17)和对照组(n＝19)。对照组仅采用优化支持治疗；减量激素组在优化支持治疗基础上使用减量泼尼松(0.5 mg·kg^－1·d^－1)，持续8周，之后每月递减5 mg，6个月后至10 mg/d长期维持。比较两组患者治疗前后血清肌酐(Scr)、24 h尿蛋白和移植肾存活率。呈正态分布和非正态分布的计量资料分别采用t检验和Mann-Whitney U检验进行比较，计数资料采用Pearson卡方检验或Fisher确切概率法进行比较，比值比(OR)用于评估相对风险；使用Kaplan-Meier法进行生存分析，并采用log-rank检验比较生存率。P<0.05为差异有统计学意义。

两组IgAN患者发生IgAN时年龄、性别、供肾类型、供者年龄、HLA错配数、ATG诱导治疗比例、肾移植后IgAN确诊时间、牛津分级评分及确诊时Scr、24 h蛋白尿水平差异均无统计学意义(P均>0.05)。随访至2025年6月，减量激素组Scr低于对照组[(117.8±30.2)和(156.7±19.2)μmol/L]，差异有统计学意义(t＝4.248，P<0.05)；24 h尿蛋白亦显著下降[0.5(0.2~1.6)和1.5(0.3~2.7)g/d]，差异有统计学意义(Z＝83.0，P<0.05)；且24 h蛋白尿<0.3 g/d的比例较高(8/17和4/19)，但差异无统计学意义(χ²＝2.731，P>0.05)，OR＝3.33(95%CI：0.78~14.31)。对照组治疗前后Scr和24 h尿蛋白水平差异均无统计学意义(t/Z＝－0.152/197.0，P均>0.05)。减量激素组治疗后Scr和24 h尿蛋白水平均低于治疗前，差异均有统计学意义(t/Z＝2.125/32.0，P均<0.05)。减量激素组3例出现高血糖、2例轻度肺部感染，均经治疗后恢复；对照组未发生不良反应。减量激素组和对照组3年移植物累计存活率分别为92.9%和81.4%，差异无统计学意义(χ²＝0.522，P>0.05)。

减量糖皮质激素联合优化支持治疗可显著改善肾移植术后IgAN患者肾功能和蛋白尿，且不良反应可控。

To investigate the effects of low-dose glucocorticoid combined with optimized supportive therapy on renal function and proteinuria in patients with recurrent or de novo IgA nephropathy (IgAN) after kidney transplantation.

A retrospective analysis was conducted on the clinical data of 36 patients with biopsy-confirmed post-transplant IgAN at Jiangxi Provincial People′s Hospital from September 2021 to December 2024. Based on whether a low-dose glucocorticoid regimen was administered, the patients were divided into the low-dose glucocorticoid group (n=17) and the control group (n=19). The control group received optimized supportive therapy alone. The low-dose glucocorticoid group received low-dose prednisone (0.5 mg·kg^-1·d^-1) for 8 weeks on top of the optimized supportive therapy, followed by a monthly reduction of 5 mg, until a long-term maintenance dose of 10 mg/d was reached after 6 months. Serum creatinine (Scr), 24-hour urinary protein, and allograft survival rates before and after treatment were compared between the two groups. Normally and non-normally distributed quantitative data were compared using the Student′s t-test and the Mann-Whitney U test, respectively. Categorical data were compared using the Pearson′s chi-square test or Fisher′s exact test. Odds ratios (ORs) were used to assess relative risk. Survival analysis was performed using the Kaplan-Meier method, and survival rates were compared using the log-rank test. A value of P<0.05 was considered statistically significant.

There were no statistically significant differences between the two groups in baseline parameters including age, sex, donor type, donor age, number of HLA mismatches, anti-thymocyte globulin (ATG) induction therapy, time from transplantation to biopsy, Oxford classification pathological scores, and baseline levels of Scr and 24-hour proteinuria at the time of biopsy (t/χ²/Z=-0.786, 0.001, 0.001, -0.485, 0.571, 0.358, 159, -0.786, 0.001, 0.001, -0.485, 0.571, 0.358, 159, all P>0.05). At the end of follow-up, the Scr level in the low-dose glucocorticoid group was significantly lower than that in the control group [(117.8±30.2) vs. (156.7±19.2) μmol/L, t=4.248, P<0.05]. The 24-hour urinary protein also decreased significantly [0.5 (0.2-1.6) vs. 1.5 (0.3-2.7) g/d, Z=83, P<0.05]. The proportion of patients achieving 24-hour proteinuria <0.3 g/d was higher in the low-dose glucocorticoid group than in the control group (8/17 vs. 4/19), though the difference was not statistically significant (χ²=2.731, P>0.05), with an OR of 3.33 (95%CI: 0.78-14.31). In the control group, there were no significant changes in Scr and 24-hour urinary protein levels before and after treatment (t/Z=-0.152/197, all P>0.05). In contrast, the Scr and 24-hour urinary protein levels in the low-dose glucocorticoid group after treatment were significantly lower than those before treatment (t/Z=2.125/32, all P<0.05). In the low-dose glucocorticoid group, 3 cases of hyperglycemia and 2 cases of mild pulmonary infection occurred, all of which recovered after management; no adverse reactions occurred in the control group. The 3-year cumulative allograft survival rates in the low-dose glucocorticoid group and the control group were 92.9% and 81.4%, respectively, with no statistically significant difference (χ²=0.522, P>0.05).

Low-dose glucocorticoid combined with optimized supportive therapy can significantly improve renal function and proteinuria control in patients with IgAN after kidney transplantation, and the adverse reactions are manageable.