Kidney Disease, Race, and GFR Estimation
Kidney Disease, Race, and GFR Estimation
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DOI：
10.2215/cjn.12791019
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发表时间：
2020-08-07
影响因子：
9.8
通讯作者：
Inker, Lesley A.
中科院分区：
文献类型：
--
作者：
Levey, Andrew S.;Titan, Silvia M.;Inker, Lesley A.
对肾小球滤过率的评估是临床实践、研究和公共卫生的核心。目前的肾脏疾病改善全球预后指南建议，作为GFR评估的初始步骤，测量血清肌酐来评估GFR。血肌酐受肌酐代谢和GFR的影响；因此，根据血肌酐估算GFR的所有公式都包括肌肉质量的替代指标，如年龄、性别、种族、身高或体重。指南推荐的成人公式(2009年慢性肾脏疾病流行病学协作肌酐公式)包括一个种族术语(指定为黑人和非黑人)，这通过考虑用于建立公式的研究人群中不同种族的血清肌酐的非GFR决定因素的差异，提高了GFR估计的准确性。在这项研究中，与年龄、性别和血清肌酐相同的非黑人相比，黑人的平均测量GFR高出16%。这种差异的原因只有一部分被理解，在GFR估计中使用RACE是有局限性的。一些人建议取消种族系数，但这将导致对黑人测量的GFR的系统性低估，从而在个人和人口层面产生潜在的意想不到的后果。我们提出了一种更谨慎的方法，以维持和提高GFR估计的准确性，并避免对任何种族群体不利。我们建议在GFR评估中充分披露种族的使用，对那些拒绝透露其种族身份的人提供便利，并在医疗保健提供者和患者之间共同做出决定。我们还建议注意使用半胱氨酸氨基转移酶C作为确证试验和清除量测量。如果有更好的、循证的替代品，最好避免在GFR估计中指定种族。未来研究的目标应该是开发更准确的方法来估计GFR，而不需要使用种族或其他人口统计特征。
Assessment of GFR is central to clinical practice, research, and public health. Current Kidney Disease Improving Global Outcomes guidelines recommend measurement of serum creatinine to estimate GFR as the initial step in GFR evaluation. Serum creatinine is influenced by creatinine metabolism as well as GFR; hence, all equations to estimate GFR from serum creatinine include surrogates for muscle mass, such as age, sex, race, height, or weight. The guideline-recommended equation in adults (the 2009 Chronic Kidney Disease Epidemiology Collaboration creatinine equation) includes a term for race (specified as black versus nonblack), which improves the accuracy of GFR estimation by accounting for differences in non-GFR determinants of serum creatinine by race in the study populations used to develop the equation. In that study, blacks had a 16% higher average measured GFR compared with nonblacks with the same age, sex, and serum creatinine. The reasons for this difference are only partly understood, and the use of race in GFR estimation has limitations. Some have proposed eliminating the race coefficient, but this would induce a systematic underestimation of measured GFR in blacks, with potential unintended consequences at the individual and population levels. We propose a more cautious approach that maintains and improves accuracy of GFR estimates and avoids disadvantaging any racial group. We suggest full disclosure of use of race in GFR estimation, accommodation of those who decline to identify their race, and shared decision making between health care providers and patients. We also suggest mindful use of cystatin C as a confirmatory test as well as clearance measurements. It would be preferable to avoid specification of race in GFR estimation if there was a superior, evidence-based substitute. The goal of future research should be to develop more accurate methods for GFR estimation that do not require use of race or other demographic characteristics.