小児紫斑病性腎炎に対する口蓋扁桃摘出術の効果 Treatment of Henoch-Schonlein Purpura Nephritis in Children with Tonsillectomy
目的:紫斑病性腎炎Henoch-Schönlein Purupura Nephritis (HSPN)はHenoch-Schönlein紫斑病の最も重要な合併症であり,その予後に大きく関与する.腎病理所見はIgA腎症と同様にIgA免疫複合体の糸球体メサンギウム領域への沈着を認め,IgA腎症に類縁の扁桃病巣感染症と考えられている.IgA腎症でみられた口蓋扁桃摘出術(扁摘)の治療効果が本疾患にも観察されるのか,扁摘を施行した小児HSPN症例に対して検討した.<br>対象と方法:1998年から2000年の間に,腎生検でHSPNの確定診断を得たうえで,内科的治療ではコントロールが困難であるために扁摘を施行した小児患者のうち術後6ヵ月以上にわたり経過を観察できた7例(男児4例,女児3例)を対象とした.手術時年齢は3歳から13歳(平均7.6±3.2歳)であった.上記に対し1)腎病理所見の重症度2)臨床所見の重症度,の2点を指標に,術前後の尿所見の変化を検討した.腎病理所見の重症度判定にはISKDC分類とIGL分類の2つを採用した.平均観察期間は74±6ヵ月であった.<br>結果:術後12ヵ月までに全例で血尿,蛋白尿とも消失していた.経過観察中に再発を認めた症例はなく,全例でステロイドを含むすべての薬剤投与が中止できた.内科的治療でコントロールが困難なHSPNにも,扁摘は有効と考えられた.
Henoch-Schönlein purpura nephritis (HSPN) is an important complication of Henoch-Schönlein purpura (HSP). Pathological findings in the kidney are similar to those for IgA nephritis, which is characterized by the deposition of IgA immune complex in the glomerular mesangium. Since a tonsillectomy is useful for IgA nephritis, this procedure holds great promise for the treatment HSPN.<br>In the present study, we assessed the effectiveness of a tonsillectomy in children with HSPN whose conditions could not be controlled by medication, including predonisone and cyclophosphamide. Seven patients (four boys and three girls) with histologically well-defined HSPN who had undergone a tonsillectomy between 1998 and 2000 and who had been followed for more than 6 postoperative months were retrospectively examined. The age of the patients ranged between 3 and 13 years (average, 7.6±3.2 years) at the time of operation. Postoperative changes in urinary data were assessed according in the severity of the pathological findings in the kidney and the patient's clinical condition. The severity of the pathological findings in the kidney was determined based on the classification of the International Study of Kidney Disease (ISKDC) and the Index of Glomeruler Lesion (IGL). All patients examined in the present study had an ISKDC classification of over grade II. One patient had a grade IV classification, 3 had a grade III classification, and 3 had a grade II classification. The patients were placed in one of five clinical groups: 1) nephritic-nephrotic syndrome, 2) acute nephritic syndrome, 3) nephritic syndrome, 4) over 1g/day of proteinuria without hypoalbuminemia or oedema, or 5) below 1g/day of proteinuria with or without hematuria. One patient was classified in group 1, 1 was group classified in 2, 2 were classified in group 3, 2 were classified in group 4 and 1 was classified in group 5. The mean observation period was 74±6.4 months.<br>The hematuria and proteinuria resolved in all patients, regardless of their preoperative pathological or clinical severity, within 12 postoperative months. During the observation period, no relapse was observed. Moreover, all medication, including steroid use, was stopped within the observation period. Therefore, a tonsillectomy was considered to be effective for the treatment of children with HSPN whose conditions cannot be controlled using medication.
日本耳鼻咽喉科學會會報 109(9), 696-702, 2006-09-20
The Oto-Rhino-Laryngological Society of Japan, Inc.