摘要
[目的]
分析系统性红斑狼疮患者发生无菌性股骨头坏死的危险因素。
[方法]
采用回顾性研究方法,以2001年1月至2010年3月之间来我院风湿免疫科住院的37例系统性红斑狼疮合并股骨头坏死的女性患者作为病例组,随机选择同时期住院的病历资料完整、激素用量明确的74例无股骨头坏死的女性系统性红斑狼疮患者以及年龄、性别相匹配的30例皮肌炎／多肌炎患者作为对照组进行回顾性研究。采用SPSS16.0统计软件,先对各个可疑危险因素进行单因素统计分析,计数资料采用x。检验,计量资料用Mann-Whitney U检验。单因素分析筛选出有统计学差异的因素共13个,结合临床实际及样本量等条件,仅对其中的10个因素进行多因素Logistic逐步回归分析,以是否发生股骨头坏死为因变量,上述10个因素作为自变量进行多因素Logistic逐步回归分析,得出与股骨头坏死有关的危险因素。
[结果]
1.37例系统性红斑狼疮合并股骨头坏死患者中有1例在发生股骨头坏死之前从未使用过激素,36例曾接受过激素治疗,其中24例股骨头坏死(66.7%)发生在激素治疗的12个月之内,32例(88.9%)股骨头坏死发生在激素治疗的24个月之内,全部患者股骨头坏死发生在激素治疗后1-30个月之间。
2.单因素统计分析：激素起始量大于60mg(P=0.006)、治疗第1个月激素平均日用量大于60mg／d(P=0.022)、第2、3月激素平均日用量(P=0.008)、第4-6月激素平均日用量(P=0.032)、第10～12月激素平均日用量(P=0.006)、突然停用激素(P=0.009)、关节疼痛(除髋关节以外)(P=0.025)、膝关节疼痛(P=0.001)、贫血(P=0.047)、SLEDAI积分(P=0.014)、高水平的抗核小体抗体(AnuA)(P=0.000)、抗SSB抗体阳性(P=0.001)、Hs-CRP(P=0.008)共13项在SLE合并ONF组与SLE无股骨头坏死组存在显著统计学差异(P<0.05)。其中SLE合并ONF组的抗SSB抗体的阳性率低于SLE对照组,并且有显著性差异。
以下指标在系统性红斑狼疮合并股骨头坏死组与系统性红斑狼疮无股骨头坏死组之间无统计学差异：狼疮发病年龄、口腔溃疡、雷诺现象、网状青斑、面部红斑、是否行激素冲击治疗、是否使用环磷酰胺。其他因素：血小板减少、白细胞减少、光过敏、脱发、发热、乏力、体重减轻、蛋白尿、肌炎、胸腔积液、狼疮肺炎、狼疮性头痛、癫痫发作、心包积液、心肌炎、心功能不全、心内膜炎、心律失常、淋巴结肿大、肝功能异常、AST、ALT、ALP、GGT阳性、白蛋白、球蛋白、抗心磷脂抗体(Acl)阳性、抗ds-DNA抗体、抗AHA抗体、抗Sm抗体、抗SSA抗体、血钙、抗rRNP抗体、补体C3、C4,免疫球蛋白IgG、IgA、IgM、血沉、24小时尿蛋白、BUN、Cr在两组SLE患者之间亦无统计学差异(P>0.05)。
3.皮肌炎／多肌炎组与系统性红斑狼疮合并股骨头坏死组比较,是否行激素冲击治疗、激素起始量、治疗第1月、2月、3月、4～6月、7～9月、10～12月、13～24月激素平均日用量无统计学差异(P>0.05)。
4.多因素Logistic回归分析结果显示：抗核小体抗体(AnuA)(P=0.001)、膝关节疼痛(P=0.009)、突然停用激素(P=0.001)、激素治疗起始量大于60mg／d(P=0.005)与系统性红斑狼疮患者发生股骨头坏死相关联。抗SSB抗体阳性与系统性红斑狼疮患者发生股骨头坏死呈负相关(P=0.021)。
[结论]
高水平的抗核小体抗体和出现膝关节疼痛的SLE患者是股骨头坏死的高危人群。为预防系统性红斑狼疮患者发生股骨头坏死,激素治疗的早期尤其是前2年要特别警惕。激素的起始剂量不宜过大,尤其是治疗的第1个月激素的平均日用量不宜超过60mg／d。激素减量要有规律,不宜突然停用激素。出现膝关节疼痛要特别警惕股骨头坏死,必要时定期做髋关节磁共振检查以发现早期股骨头坏死并采取相应措施。
[Objective]
To analyse the risk factors of osteonecrosis of the femoral head(ONF) in systemic lupus erythematosus(SLE).
【Methods】
Case-control study was made in our research.Case group was made up of 37 female SLE who have developed ONF. They were in-patients of Rheumatology and Immunology from January,2001 to March,2010.Information on clinical presentation,laboratory examination results and corticosteroid usage was obtained,and comparison was made between these patients and 74 control SLE patients who did not develope ONF. At the same time,we compared the usage of corticosteroid between these SLE patients who had ONF and 30 dermatomyositis/polymyositis patients who do not have ONF.Case group and control groups were match in gender and age and were in-patients from the same period.SPSS 16.0 statistical software were adopted.First,every suspected factors were analysed separately, Chi-Square test was adopted for classification variables and Mann-Whitney U test was adopted for numerical variables.13 factors were found to have statistical significance in the one-factor analysis above.Then multiple factor Logistic regression analysis was made.
【Results】
1. There was one SLE patient with ONF had never used glucocorticoid before she developed ONF in the 37 SLE patiens with ONF.36 patients had used glucocorticoid,and 24 patients(66.7%) developed ONF during the first 12 months after using glucocorticoid,32 patients(88.9%) developed ONF during 24 months after using glucocorticoid。
2. One-factor statistical analysis:the following variables were found to exist statistical significance between case group and control group:the highest prednisolone dose more than 60mg/d,mean daily prednisolone dose more than 60mg/d in the first month,mean daily dose in the second and third months,4th to 6th months and 10th to 12th months,a sudden stop of using glucocorticoid,heamolytic anaemia, arthralgia,pain of kneens,SLE Disease Activity Index(SLEDAI), anti-AnuA, anti-SSB,Hs-CRP.The following variables were found to have no statistical significance:fever,age at onset of disease,oral ulcer,photosensitivity,CNS disease, serositis,Raynauds phenomenon,alop-ecia,cutaneous vasculitis, leucopenia, thrombocytopenia,arthralgia,anti-dsDNA,anti-sm,anti-rRNP,anti-AHA, and so on.
3. Comparison was made between 37 SLE patients with osteonecrosis of the femoral head and dermatomyositis/polymyositis group.The following variables were found to have no statistical significance between the two groups:pulse methylprednisolone,the initial dose of glucocorticoid,, mean daily dose in the first month,in the second and third month,4th to 6th month,7th to 9th,10th to 12th,and 13th to 24th months.
4. Multiple factor Logistic regression analysis:anti-AnuA, sudden stop of using glucocorticoid, pain of knees, the highest prednisolone dose more than 60mg/d,mean daily prednisolone dose more than 60mg/d in the first month have relationship with ONF in SLE patients.
[Conclusions]
To avoid developing ONF in SLE patients,the initial therapy with glucocorticoid is very important,especially in the first year.It is inadvisable to give a too high dose of glucocoticoid,especially the first month of therapy,mean daily dose is inadvisable to exceed 60mg/d.A sudden stop of using glucocorticoid is also an independent risk factor associated with ONF.These who had a pain of kneens should be on guard against ONF,magnetic resonance imaging examination should be given at regular intervals in order to detect ONF at an early stage.High level of anti-AnuA is also an independent risk factor for ONF.
引文
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