Relation Between Kidney Function, Proteinuria, and Adverse Outcomes
Relation Between Kidney Function, Proteinuria, and Adverse Outcomes
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DOI：
10.1001/jama.2010.39
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发表时间：
2010-02-03
影响因子：
120.7
通讯作者：
Tonelli, Marcello
中科院分区：
文献类型：
--
作者：
Hemmelgarn, Brenda R.;Manns, Braden J.;Tonelli, Marcello
目前慢性肾脏疾病的分期系统主要基于估计的肾小球滤过率（eGFR），较低的eGFR与较高的不良结局风险相关。尽管蛋白尿也与不良后果相关，但在目前的系统中，它并没有被用于改进不良事件的风险估计。目的探讨GFR降低、蛋白尿和不良临床结果之间的关系。设计、环境和参与者：以社区为基础的队列研究，参与者从2002年至2007年加拿大艾伯塔省的一个全省范围的实验室登记中确定，包括eGFR和蛋白尿测量。有920985名成年人至少进行了一次门诊血清肌酐测量，并且在基线时不需要肾脏替代治疗。蛋白尿用尿试纸或白蛋白-肌酐比（ACR）测定。主要结局指标：全因死亡率、心肌梗死和进展为肾衰竭。结果绝大多数（89.1%）患者eGFR≥60 mL/min/1.73 m(2)。中位随访35个月（范围0-59个月），27959名参与者（3.0%）死亡。在egfr较低或蛋白尿较多的研究参与者中，完全调整后的全因死亡率更高。与eGFR为45 - 59.9 mL/min/1.73 m(2)和蛋白质排泄正常的患者相比，尿量尺测重蛋白尿且eGFR为60 mL/min/1.73 m(2)或更高的患者校正死亡率高出2倍以上（比率，每1000人年7.2 [95% CI, 6.6-7.8] vs 2.9 [95% CI, 2.7-3.0]；比率比，2.5 [95% CI, 2.3-2.7]）。当用ACR测量蛋白尿时，观察到类似的结果（重度蛋白尿和无蛋白尿分别为每1000人年15.9 [95% CI, 14.0-18.1]和7.0 [95% CI, 6.4-7.6]；比率为2.3 [95% CI, 2.0-2.6]），以及急性心肌梗死住院、终末期肾病和血清肌酐水平翻倍的结果。结论：在蛋白尿水平较高的患者中，与给定eGFR水平相关的死亡、心肌梗死和进展为肾衰竭的风险独立增加。《美国医学协会杂志》上。2010年;303 (5): 423 - 429 www.jama.com
Context The current staging system for chronic kidney disease is based primarily on estimated glomerular filtration rate (eGFR) with lower eGFR associated with higher risk of adverse outcomes. Although proteinuria is also associated with adverse outcomes, it is not used to refine risk estimates of adverse events in this current system.Objective To determine the association between reduced GFR, proteinuria, and adverse clinical outcomes.Design, Setting, and Participants Community-based cohort study with participants identified from a province-wide laboratory registry that includes eGFR and proteinuria measurements from Alberta, Canada, between 2002 and 2007. There were 920 985 adults who had at least 1 outpatient serum creatinine measurement and who did not require renal replacement treatment at baseline. Proteinuria was assessed by urine dipstick or albumin-creatinine ratio (ACR).Main Outcome Measures All-cause mortality, myocardial infarction, and progression to kidney failure.Results The majority of individuals (89.1%) had an eGFR of 60 mL/min/1.73 m(2) or greater. Over median follow-up of 35 months ( range, 0-59 months), 27 959 participants (3.0%) died. The fully adjusted rate of all-cause mortality was higher in study participants with lower eGFRs or heavier proteinuria. Adjusted mortality rates were more than 2-fold higher among individuals with heavy proteinuria measured by urine dipstick and eGFR of 60 mL/min/1.73 m(2) or greater, as compared with those with eGFR of 45 to 59.9 mL/min/1.73 m(2) and normal protein excretion (rate, 7.2 [95% CI, 6.6-7.8] vs 2.9 [95% CI, 2.7-3.0] per 1000 person-years, respectively; rate ratio, 2.5 [95% CI, 2.3-2.7]). Similar results were observed when proteinuria was measured by ACR (15.9 [ 95% CI, 14.0-18.1] and 7.0 [95% CI, 6.4-7.6] per 1000 person-years for heavy and absent proteinuria, respectively; rate ratio, 2.3 [95% CI, 2.0-2.6]) and for the outcomes of hospitalization with acute myocardial infarction, end-stage renal disease, and doubling of serum creatinine level.Conclusion The risks of mortality, myocardial infarction, and progression to kidney failure associated with a given level of eGFR are independently increased in patients with higher levels of proteinuria. JAMA. 2010;303(5):423-429 www.jama.com