Variability and risk factors for kidney disease progression and death following attainment of stage 4 CKD in a referred cohort
Variability and risk factors for kidney disease progression and death following attainment of stage 4 CKD in a referred cohort
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DOI：
10.1053/j.ajkd.2008.06.023
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发表时间：
2008-10-01
影响因子：
13.2
通讯作者：
Er, Lee
中科院分区：
文献类型：
--
作者：
Levin, Adeera;Djurdjev, Ognjenka;Er, Lee
背景：在大型队列研究中，转诊至肾病学家的患者的结果并未得到很好的描述。这项分析的目的是描述肾脏疾病快速进展和死亡的预测因素。研究设计：回溯性研究。背景和参与者：从省级数据库登记的所有患者中形成一个队列，包括2000年1月至2004年1月期间所有指数估计肾小球滤过率(EGFR)小于30毫升/分钟/1.73米(2)的患者，至少3个后续的EGFR值，以及4个月的随访。预测因素：用于预测结果的变量包括基线EGFR，在EGFR之前的随访时间小于30毫升/分钟/1.73米(2)，年龄，性别、种族、糖尿病、血压、蛋白尿水平、血红蛋白水平、磷酸盐水平、钙水平、甲状旁腺激素水平，以及血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、促红细胞生成剂和维生素D的使用。结果：主要结果是死亡、开始透析治疗或GFR丢失>5毫升/分钟/1.73米(2)/次。结果：4,231名患者符合纳入标准。平均年龄67岁。中位随访时间为31个月。在前两年的随访中，24%的患者开始了透析治疗，1%的患者接受了移植，7%的患者死亡，1%的患者失访。与肾脏疾病进展更快相关的统计学显著变量不同于那些预测死亡的变量。年龄较小、男性、较高的EGFR、较高的收缩压和代谢性血压、较低的血红蛋白水平、较高的磷和甲状旁腺激素水平以及较多的蛋白尿与肾脏疾病进展较快相关，使用血管紧张素转换酶/血管紧张素受体阻滞剂具有保护作用。高龄、较低的舒张压、较低的血红蛋白水平以及较高的磷和甲状旁腺激素水平与死亡有关，而维生素D的使用具有保护作用。局限性：研究结果不能推广到EGFR小于30mL/min/1.73m(2)的未转诊患者。结论：慢性肾脏病4期患者的临床病程是不同的。针对可改变的危险因素的靶向治疗需要进行评估，以确定该方法的益处。
Background: The outcomes of patients referred to nephrologists are not well described in large cohorts. The objectives of this analysis are to describe the predictors of rapid progression of kidney disease and death in patients followed up by nephrologists.Study Design: Retrospective study.Setting & Participants: A cohort derived from all patients registered in the provincial database was formed that included all patients with index estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m(2), at least 3 subsequent eGFR values, and 4 months of follow-up between January 2000 and January 2004.Predictors: Variables used to predict outcomes included baseline eGFR, duration of follow-up before eGFR less than 30 mL/min/1.73 m(2), age, sex, ethnicity, presence of diabetes, blood pressure, level of proteinuria, hemoglobin level, phosphate level, calcium level, parathyroid hormone level, and use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, erythropoiesis-stimulating agents, and vitamin D.Outcomes: Key outcomes of interest were death, dialysis therapy start, or loss of GFR greater than 5 mL/min/1.73 m(2)/y.Results: 4,231 patients met inclusion criteria. Mean age was 67 years. Median follow-up was 31 months. During the first 2 years of follow-up, 24% started dialysis therapy, 1% received a transplant, 7% died, and 1% was lost to follow-up. Statistically significant variables associated with more rapid kidney disease progression differ from those that predict death. Younger age, male sex, higher eGFR, higher systolic and diabolic blood pressure, lower hemoglobin level, higher phosphorus and parathyroid hormone levels, and greater proteinuria are associated with more rapid kidney disease progression, and use of angiotensin-converting enzymes/angiotensin receptor blockers are protective. Older age, lower diastolic blood pressure, lower hemoglobin level, and higher phosphorous and parathyrold hormone levels are associated with death, whereas vitamin D use is protective. Limitations: Results cannot be generalized to unreferred patients with eGFR less than 30 mL/min/1.73 m(2).Conclusion: The clinical course of patients with chronic kidney disease stage 4 is variable. Targeted therapy aimed at modifiable risk factors needs to be evaluated to determine benefits of this approach.