Predictivity of survival according to different equations for estimating renal function in community-dwelling elderly subjects
Predictivity of survival according to different equations for estimating renal function in community-dwelling elderly subjects
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DOI：
10.1093/ndt/gfn594
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发表时间：
2009-04-01
影响因子：
6.1
通讯作者：
Guralnik, Jack M.
中科院分区：
文献类型：
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作者：
Pizzarelli, Francesco;Lauretani, Fulvio;Guralnik, Jack M.
背景早期慢性肾脏病（CKD）受试者的检测非常重要，因为有些受试者将进展至5期CKD，并且大多数受试者处于心血管发病率和死亡率的高风险中。虽然已经反复研究了估计肾小球滤过率（eGFR）方程在追踪真实GFR中的有效性和精确性，但迄今为止尚未比较其对死亡率的预后性能。这在老年人群中尤其相关，在老年人群中死亡风险远比进展更常见。我们分析了InCHIANTI研究参与者的数据，这是一项基于社区的老年人队列研究。24小时肌酐清除率（Ccr）、Cockcroft-Gault（C-G）和肾脏疾病饮食改良（MDRD）衍生方程（6个和4个输入变量）在入组时计算（1998-2000），全因死亡率和心血管死亡率通过6年随访的考克斯回归进行前瞻性确定。在1270名参与者中，942名（平均年龄75岁）有本研究的完整数据。平均肾功能范围为77 ml/min/1.73 m2（Ccr）至64 ml/min/1.73 m2（C-G）。使用K/DOQI分期的方程之间的比较突出了相关的不匹配，CKD的患病率范围从22%（MDRD-4）到40%（C-G）。肾功能下降是死亡的一个强有力的独立预测因子。在一个考克斯模型中-校正了人口统计学、体力活动、合并症、蛋白尿和炎症参数-Ccr 60-90 ml/min/1.73 m（2）和Ccr 90 ml/min/1.73 m（2）的参与者。对于C-G，数值90 ml/min/1.73 m（2）的组（HR 2.59，95% CI：1.13-5.91）。基于MDRD公式的分类没有提供任何显著的预后信息。当Ccr和估计方程作为连续变量引入或二分为高于或低于60 ml/min时，全因死亡率的校正风险遵循类似的模式。C-G是心血管死亡率的最佳预后指标。Ccr和C-G可能是比MDRD公式更好的预后指标，因为它们包含了更强的年龄效应。在南欧老年人群中，CKD的患病率很高，并且根据估计GFR所采用的方法差异很大。研究人员和临床医生如果希望获得与肾功能相关的死亡率的预后信息，应使用Ccr或C-G公式，而不是MDRD公式。这些结果强调了老年受试者早期发现和临床管理慢性肾病策略的重要性。
Background. Detection of subjects with early chronic kidney disease (CKD) is important because some will progress up to stage 5 CKD, and most are at high risk of cardiovascular morbidity and mortality. While validity and precision of estimated glomerular filtration rate (eGFR) equations in tracking true GFR have been repeatedly investigated, their prognostic performance for mortality has not been hitherto compared. This is especially relevant in an elderly population in whom the risk of death is far more common than progression.Methods. We analysed data of participants in the InCHIANTI study, a community-based cohort study of older adults. Twenty-four-hour creatinine clearance (Ccr), Cockcroft-Gault (C-G) and Modification of Diet in Renal Disease (MDRD)-derived equations (six and four input variables) were calculated at enrolment (1998-2000), and all-cause mortality and cardiovascular mortality were prospectively ascertained by Cox regression over a 6-year follow-up.Results. Of the 1270 participants, 942 (mean age 75 years) had complete data for this study. The mean renal function ranged from 77 ml/min/1.73 m(2) by Ccr to 64 ml/min/1.73 m(2) by C-G. Comparisons among equations using K/DOQI staging highlight relevant mismatches, with a prevalence of CKD ranging from 22% (MDRD-4) to 40% (C-G). Reduced renal function was a strong independent predictor of death. In a Cox model-adjusted for demographics, physical activity, comorbidities, proteinuria and inflammatory parameters-participants with Ccr 60-90 ml/min/1.73 m(2) and Ccr 90 ml/min/1.73 m(2). For the C-G, the group with values 90 ml/min/1.73 m(2) (HR 2.59, 95% CI: 1.13-5.91). The classification based on the MDRD formulae did not provide any significant prognostic information. The adjusted risk of all-cause mortality followed a similar pattern when Ccr and estimating equations were introduced as continuous variables or dichotomized as higher or lower than 60 ml/min. C-G was the best prognostic indicator of cardiovascular mortality. Possibly, Ccr and C-G are better prognostic indicators than MDRD-derived equations because they incorporate a stronger effect of age.Conclusions. In a South-European elderly population, the prevalence of CKD is high and varies widely according to the method adopted to estimate GFR. Researchers and clinicians who want to capture the prognostic information on mortality related to kidney function should use the Ccr or C-G formula and not MDRD equations. These results highlight the importance of strategies for early detection and clinical management of CKD in elderly subjects.