Tonelli Marcello, Wiebe Natasha, Culleton Bruce, House Andrew, Rabbat Chris, Fok Mei, McAlister Finlay, Garg Amit X
Department of Medicine, University of Alberta, Edmonton, Alberta T6B 2B7, Canada.
J Am Soc Nephrol. 2006 Jul;17(7):2034-47. doi: 10.1681/ASN.2005101085. Epub 2006 May 31.
Current guidelines identify people with chronic kidney disease (CKD) as being at high risk for cardiovascular and all-cause mortality. Because as many as 19 million Americans may have CKD, a comprehensive summary of this risk would be potentially useful for planning public health policy. A systematic review of the association between non-dialysis-dependent CKD and the risk for all-cause and cardiovascular mortality was conducted. Patient- and study-related characteristics that influenced the magnitude of these associations also were investigated. MEDLINE and EMBASE databases were searched, and reference lists through December 2004 were consulted. Authors of 10 primary studies provided additional data. Cohort studies or cohort analyses of randomized, controlled trials that compared mortality between those with and without chronically reduced kidney function were included. Studies were excluded from review when participants were followed for < 1 yr or had ESRD. Two reviewers independently extracted data on study setting, quality, participant and renal function characteristics, and outcomes. Thirty-nine studies that followed a total of 1,371,990 participants were reviewed. The unadjusted relative risk for mortality in participants with reduced kidney function compared with those without ranged from 0.94 to 5.0 and was significantly more than 1.0 in 93% of cohorts. Among the 16 studies that provided suitable data, the absolute risk for death increased exponentially with decreasing renal function. Fourteen cohorts described the risk for mortality from reduced kidney function, after adjustment for other established risk factors. Although adjusted relative hazards were consistently lower than unadjusted relative risks (median reduction 17%), they remained significantly more than 1.0 in 71% of cohorts. This review supports current guidelines that identify individuals with CKD as being at high risk for cardiovascular mortality. Determining which interventions best offset this risk remains a health priority.
当前指南将慢性肾脏病（CKD）患者确定为心血管疾病和全因死亡的高危人群。由于多达1900万美国人可能患有CKD，对这种风险进行全面总结可能有助于制定公共卫生政策。我们对非透析依赖型CKD与全因死亡及心血管死亡风险之间的关联进行了系统评价。还研究了影响这些关联程度的患者和研究相关特征。检索了MEDLINE和EMBASE数据库，并查阅了截至2004年12月的参考文献列表。10项主要研究的作者提供了额外数据。纳入了比较肾功能长期降低者与未降低者死亡率的队列研究或随机对照试验的队列分析。当参与者随访时间<1年或患有终末期肾病（ESRD）时，研究被排除在综述之外。两名研究者独立提取关于研究背景、质量、参与者和肾功能特征以及结局的数据。共对39项研究进行了综述，这些研究共纳入1371990名参与者。肾功能降低的参与者与未降低者相比，未调整的死亡相对风险范围为0.94至5.0，在93%的队列中显著高于1.0。在提供合适数据的16项研究中，死亡绝对风险随着肾功能下降呈指数增加。14个队列描述了在调整其他既定风险因素后，肾功能降低导致的死亡风险。尽管调整后的相对风险一直低于未调整的相对风险（中位数降低17%），但在71%的队列中仍显著高于1.0。本综述支持当前指南，即确定CKD患者为心血管死亡的高危人群。确定哪些干预措施能最好地抵消这种风险仍然是卫生领域的优先事项。
