IgA nephropathy (IgAN) is the most common primary glomerular disease, and one major cause of malignant hypertension (MHT) secondary to renal parenchymal disease. The clinical conditions and severity of renal lesion have been reported to be more serious when IgAN is accompanied by MHT, but risk factors of MHT in IgAN analyzed from Traditional Chinese Medicine (TCM) perspective are still unclear.

To explore the TCM-related factors and pathogenesis associated with MHT in IgAN patients.

From 518 cases of primary IgAN who were diagnosed by renal biopsy in First Medical Center of Chinese PLA General Hospital during December 2013 to September 2021, a sample of 12 cases accompanied by MHT (IgAN-MHT group) computed by PASS 15.0 were selected for correlation power analysis, and they were matched at a ratio of 1∶5 with other randomly selected 85 cases without MHT (IgAN group) . Clinical, pathological and TCM syndromes between the two groups were compared. Lasso regression was used to screen 93 TCM syndromes, among which those with significant associations with IgAN-MHT were identified by multivariate Logistic regression.

Compared with IgAN group, IgAN-MHT group had higher prevalence of headache and dizziness or nausea and vomiting as the first clinical manifestations, and clinically diagnosed nephrotic syndrome, higher levels of baseline mean arterial pressure, highest systolic and diastolic blood pressure, blood urea nitrogen, serum creatinine, serum inorganic phosphorus, serum magnesium, and quantitatively estimated 24-hour urinary protein excretion, higher prevalence of CKD stages 3-5, blood stasis syndrome, subtypes of qi-deficiency syndromes (including mental fatigue and lack of strength, limb fatigue, tibia and leg weakness, dizziness, headache with nausea, and vomiting) , subtypes of yin-deficiency syndromes (including blurred vision and eye floaters) , subtypes of blood stasis syndromes (including nail cyanosis, and dark purple tongue) , and intrarenal arteriosclerosis (P<0.05) . Moreover, IgAN-MHT group had lower prevalence of abnormal urine test results as the first clinical manifestations, previous hypertension and clinical diagnosed chronic nephritic syndrome, as well as lower levels of mean serum IgM and IgG levels, and eGFR (P<0.05) . Both groups had no significant difference in the prevalence of interstitial fibrosis/tubular atrophy (T) lesions among the two groups (P<0.05) . The common TCM syndrome in IgAN-MHT group was qi-yin deficiency syndrome combined with blood stasis syndrome. Correlation analysis showed that IgAN-MHT was positively associated with blood stasis syndrome (P<0.05) ; in IgAN-MHT group, male and quantitatively estimated 24-hour urinary protein excretion was positively associated with qi-deficiency syndrome (P<0.05) ; serum inorganic phosphorus and potassium was negatively associated with yin-deficiency syndrome (P<0.05) , and renal tubular atrophy/interstitial fibrosis was positively associated with blood stasis syndrome (P=0.040) . Multivariate Logistic regression analysis showed that headache〔OR=7.895, 95%CI (1.643, 37.935) , P=0.010〕, blurred vision〔OR=5.499, 95%CI (1.207, 25.053) , P=0.028〕, dry mouth with desire for drink 〔OR=10.079, 95%CI (2.289, 44.373) , P=0.002〕, and nail cyanosis〔OR=18.312, 95%CI (2.179, 153.884) , P=0.007〕 were associated with MHT in IgAN.

IgAN-MHT patients had worse renal function and more serious renal pathological damage. The common TCM syndrome in IgAN-MHT was qi-yin deficiency syndrome with blood stasis syndrome. The clinical and pathological indices of IgAN-MHT patients had a certain level of correlation with qi-deficiency syndrome, yin-deficiency syndrome and blood stasis syndrome. The subtypes of TCM syndromes, such as headache, blurred vision, dry mouth with desire for drink, and nail cyanosis were the influencing factors of MHT in IgAN. Early detection, diagnosis and treatment, concern for and improvement of symptoms related to syndromes of qi-deficiency, yin-deficiency, and blood stasis, may contribute to decreased risk of MHT in IgAN.

IgA肾病（IgAN）是全世界最常见的原发性肾小球疾病，同时也是引起肾实质恶性高血压（MHT）的主要原因之一。既往研究认为伴MHT的IgAN临床病情和肾脏病变程度均比无MHT的IgAN严重，但尚不清楚IgAN患者发生MHT的中医证候特点。

分析原发性IgAN患者发生MHT的中西医相关因素，探索其中医证候特点。

纳入2013年12月至2021年9月在中国人民解放军总医院第一医学中心经肾穿刺活检确诊的518例原发性IgAN患者为研究对象，应用PASS 15.0软件中的变量相关性检验进行样本量估算，最终纳入伴MHT的IgAN患者17例作为IgAN-MHT组，按照1∶5比例随机抽取同时期85例无MHT的IgAN患者作为IgAN组，比较两组临床、病理及中医证候的差异。采用Lasso回归对93个中医证候信息进行筛选降维，进一步采用多因素Logistic回归分析探讨伴MHT的IgAN的中医证候相关因素。

IgAN-MHT组首发临床表现为头痛头晕或恶心呕吐比例，临床诊断为肾病综合征比例，入院时平均动脉压、最高收缩压、最高舒张压、血尿素氮、血肌酐、血无机磷、血镁、24 h尿蛋白定量水平、慢性肾脏病（CKD） 3~5期的比例、血瘀证比例，气虚证中神疲乏力、四肢倦怠、胫酸腿软、头目眩晕、头痛、恶心、呕吐症状的比例，阴虚证中视物模糊、飞蚊症症状的比例，血瘀证中爪甲青紫、舌色紫暗症状的比例，肾内动脉硬化比例高于IgAN组；而首发临床表现为尿检异常比例、高血压病史比例、临床诊断为慢性肾炎综合征的比例、血IgM、血IgG水平、估算肾小球滤过率（eGFR）水平低于IgAN组（P<0.05）。两组伴肾小管萎缩/间质纤维化病变（T病变）比例比较，差异有统计学意义（P<0.05）。IgAN-MHT组的常见中医证型为气阴两虚兼血瘀证。IgAN-MHT和血瘀证呈正相关（P<0.05），IgAN-MHT患者男性比例、24 h尿蛋白定量水平和气虚证呈正相关（P<0.05），无机磷、血钾和阴虚证呈负相关（P<0.05），IgAN-MHT患者肾小管萎缩/间质纤维化和血瘀证呈正相关（P=0.040）。多因素Logistic回归分析结果显示，头痛〔OR=7.895，95%CI（1.643，37.935），P=0.010〕、视物模糊〔OR=5.499，95%CI（1.207，25.053），P=0.028〕、口干喜饮〔OR=10.079，95%CI（2.289，44.373），P=0.002〕、爪甲青紫〔OR=18.312，95%CI（2.179，153.884），P=0.007〕是伴MHT的原发性IgAN的影响因素。

（1）伴MHT的原发性IgAN患者肾功能更差，肾脏病理损伤更重。（2）伴MHT的原发性IgAN的常见中医证型为气阴两虚兼血瘀证。（3）伴MHT的原发性IgAN患者临床、病理指标与中医气虚证、阴虚证和血瘀证具有一定相关性。（4）中医证候中头痛、视物模糊、口干喜饮、爪甲青紫是伴MHT的原发性IgAN相关因素。早发现、早诊断、早治疗，关注并改善患者的气虚、阴虚、血瘀相关症状，有可能减少IgAN患者伴MHT的发生。