IgA nephropathy (IgAN) is a common primary glomerulonephritis worldwide, and the improvement of glucocorticoid on the renal prognosis of IgAN patients with high risk of CKD progression remains unclear.

To explore the effect of glucocorticoid therapy on the therapeutic response and renal prognosis of IgAN patients with high risk of CKD progression.

IgAN patients with high risk of CKD progression were recruited in the First Affiliated Hospital of Zhengzhou University from January 2017 to October 2021 as study subjects and divided into the glucocorticoid treatment group and supportive treatment group according to whether glucocorticoid therapy was performed. Propensity matching method (PSM) was used to screen patients for cases by 1∶1 matching according to gender, age, 24 h urine protein and eGFR, the clinicopathological data of patients, disease remission, adverse reactions within 1 year were recorded. The patients were followed up from the date of initiation of supportive therapy until October 31, 2022. The primary endpoint event was defined as progression to end-stage renal disease (ESRD) or receiving dialysis. The composite endpoint event was defined as sustained decline in eGFR of more than 30% from baseline, or progression to ESRD, or receiving dialysis or death. Kaplan-Meier method was used to plot survival curves and log-rank test was used to compare differences in the cumulative incidence of the primary/composite endpoint events between the two groups of patients. Cox proportional hazards regression analysis was used to analyze the possible influencing factors of renal prognosis in IgAN patients with high risk of CKD progression.

A total of 236 patients with primary IgAN met the inclusion criteria. After 1∶1 matching, 97 cases in the glucocorticoid treatment group were successfully matched with 97 cases in the supportive therapy group with balanced baseline data. The complete remission rate and partial remission rate of patients in the glucocorticoid treatment group were higher than those in supportive treatment group (χ²=6.171, P=0.013; χ²=3.973, P=0.046) . The median follow-up time was 18.00 (9.75, 28.00) months. Kaplan-Meier survival curve analysis showed that the cumulative incidence of primary endpoint event in the glucocorticoid treatment group was lower than the supportive treatment group (χ²=4.495, P=0.034) and the cumulative survival rate of composite endpoint event in the glucocorticoid therapy group was lower than the supportive therapy group (χ²=4.419, P=0.036) . Among the 236 patients who met the inclusion criteria, there were 177 patients with moderate proteinuria. After 1∶1 matching of the 177 patients on glucocorticoid treatment and supportive treatment by sex, age, 24 h urine protein and eGFR using PSM, 76 cases in each group were successfully matched. Kaplan-Meier survival curve analysis showed that the cumulative incidence of primary endpoint event in the patients on glucocorticoid treatment with moderate proteinuria was lower than those on supportive treatment with moderate proteinuria (χ²=4.127, P=0.042) ; and the cumulative survival rate of composite endpoint event in the patients on glucocorticoid treatment with moderate proteinuria was lower than those on supportive treatment with moderate proteinuria (χ²=4.934, P=0.026) . Multivariate Cox proportional hazard regression analysis showed that hemoglobin (HR=0.982) , serum creatinine (HR=1.019) , eGFR (HR=1.020) and 24-hour urine protein (HR=1.205) were influencing factors of primary endpoints event in IgAN patients with high risk of CKD progression. The incidence of infection in the glucocorticoid treatment group was higher than the supportive treatment group (P<0.05) .

In IgAN patients with high risk of CKD progression, compared with simple supportive treatment, glucocorticoid treatment can significantly improve the renal remission rate and reduce the risk of renal function decline and renal failure. However, it is still necessary to be alert to its adverse reactions.

IgA肾病（IgAN）是世界范围内常见的原发性肾小球肾炎之一，目前糖皮质激素是否能改善慢性肾脏病（CKD）进展高风险IgAN患者肾脏预后尚无明确结论。

本研究旨在探讨激素治疗对CKD进展高风险IgAN患者的治疗反应及肾脏预后的影响。

回顾性纳入2017年1月—2021年10月于郑州大学第一附属医院就诊的CKD进展高风险IgAN患者。根据是否进行激素治疗将患者分为激素治疗组和支持治疗组，采用倾向匹配法按照性别、年龄、24 h尿蛋白定量、估算肾小球滤过率（eGFR）对患者进行1∶1匹配筛选病例，收集患者的临床及病理资料，记录患者治疗1年内疾病缓解情况及不良反应发生情况。以开始支持治疗的日期作为随访起点，随访至2022-10-31，主要终点事件定义为：进展为终末期肾脏病（ESRD）或接受透析治疗。复合终点事件定义为：eGFR较基线持续下降超过30%或进入ESRD或接受透析或患者死亡；运用Kaplan-Meier法绘制生存曲线，并采用Log-rank检验比较两组患者主要/复合终点事件累积发生率的差异。运用Cox比例风险回归分析探究影响CKD进展高风险IgAN患者预后的可能因素。

共有236例原发性IgAN患者符合纳入标准，经过1∶1匹配，激素治疗组97例与支持治疗组97患者匹配成功，两组基线数据匹配均衡。激素治疗组患者完全缓解率、部分缓解率均高于支持治疗组（χ²=6.171，P=0.013；χ²=3.973，P=0.046）。中位随访时间为18.00（9.75，28.00）个月。Kaplan-Meier生存分析结果显示，激素治疗组的主要终点事件累积发生率低于支持治疗组（χ²=4.495，P=0.034）；激素治疗组的复合终点事件累积发生率低于支持治疗组（χ²=4.419，P=0.036）。符合纳入标准的236例患者中有177例中等量蛋白尿患者，采用倾向匹配法按照性别、年龄、24 h尿蛋白定量、eGFR对激素治疗和支持治疗的177例患者进行1∶1匹配后，激素治疗中等量蛋白尿者和支持治疗中等量蛋白尿者各有76例患者匹配成功。Kaplan-Meier生存曲线结果显示，激素治疗中等量蛋白尿者的主要终点事件累积发生率低于支持治疗中等量蛋白尿者（χ²=4.127，P=0.042）；激素治疗中等量蛋白尿者的复合终点事件累积发生率低于支持治疗中等量蛋白尿者（χ²=4.934，P=0.026）。多因素Cox比例风险回归分析结果显示血红蛋白（HR=0.982）、血肌酐（HR=1.019）、eGFR（HR=1.020）、24 h尿蛋白定量（HR=1.205）是影响CKD进展高风险IgAN患者发生主要终点事件的影响因素（P<0.05）。激素治疗组感染发生率高于支持治疗组（P<0.05）。

在CKD进展高风险IgAN肾病患者中，与单纯支持治疗相比，激素治疗可以显著提升肾脏缓解率，降低肾功能下降、肾衰竭风；但仍需警惕其不良反应的发生。