Conway Bryan, Webster Angela, Ramsay George, Morgan Neal, Neary John, Whitworth Caroline, Harty John
Department of Renal Medicine, Royal Infirmary Edinburgh, Edinburgh, UK.
Nephrol Dial Transplant. 2009 Jun;24(6):1930-7. doi: 10.1093/ndt/gfn772. Epub 2009 Jan 30.
Novel strategies are required to efficiently manage the increasing number of patients diagnosed with chronic kidney disease (CKD). We sought to identify factors predicting outcome in patients with stage 4 CKD and to determine whether low-risk patients could be managed in primary care.
We performed a two-centre, retrospective cohort study including 396 patients with stage 4 CKD referred to nephrology clinics from 1998 to 2002. We utilized electronic databases to determine the incidence of renal replacement therapy (RRT) and mortality and the rate of deterioration in estimated glomerular filtration rate (eGFR) to the year end 2005.
This was an elderly cohort, with 71.7% of patients aged > or =65 years. The risk of surviving to require dialysis fell with increasing age (HR 0.44; 95% CI: 0.23-0.84 for those >74 years verses those <65 years), in part due to the slower rate of decline in renal function in older patients (median fall in eGFR was -2.25, -1.38 and -0.86 ml/ min/1.73 m(2)/year in those aged <65 years, 65-74 years and >74 years, respectively, P < 0.0001). Additional independent risk factors predicting RRT included: high baseline proteinuria (HR 6.26; 95% CI: 2.74-14.23 for >3 g/24 h versus <0.3 g/24 h), greater early decline in renal function (HR 3.86; 95% CI: 2.34-6.38 for > or =4 ml/min/1.73 m(2)/year versus <4 ml/min/1.73 m(2)/year), low baseline eGFR (HR 2.92; 95% CI: 1.61-5.30 for 15-19 versus 25-29 ml/min/1.73 m(2)) and low haemoglobin (HR 3.16; 95% CI: 1.64-6.08 for <10 versus >12 g/dl). The 98 (24.7%) patients discharged to primary care had more stable renal function than those remaining under nephrology care (median change in eGFR of +0.20 versus -1.88 ml/ min/1.73 m(2)/year, P = 0.0001).
Most patients with stage 4 CKD, in particular the elderly, die without commencing RRT. Patients at low risk of progression can be identified and discharged safely to primary care with an active management plan.
需要新的策略来有效管理诊断为慢性肾脏病（CKD）的患者数量不断增加的情况。我们试图确定预测4期CKD患者预后的因素，并确定低风险患者是否可以在初级保健中进行管理。
我们进行了一项双中心回顾性队列研究，纳入了1998年至2002年转诊至肾脏病诊所的396例4期CKD患者。我们利用电子数据库确定至2005年底肾替代治疗（RRT）的发生率、死亡率以及估计肾小球滤过率（eGFR）的恶化率。
这是一个老年队列，71.7%的患者年龄≥65岁。随着年龄增长，存活至需要透析的风险降低（74岁及以上患者与65岁以下患者相比，风险比[HR]为0.44；95%置信区间[CI]：0.23 - 0.84），部分原因是老年患者肾功能下降速度较慢（eGFR的中位数下降分别为：65岁以下患者为 - 2.25，65 - 74岁患者为 - 1.38，74岁及以上患者为 - 0.86 ml/min/1.73 m²/年，P < 0.0001）。预测RRT的其他独立风险因素包括：高基线蛋白尿（24小时尿蛋白>3 g与<0.3 g相比，HR为6.26；95% CI：2.74 - 14.23）、肾功能早期下降幅度更大（eGFR下降≥4 ml/min/1.73 m²/年与<4 ml/min/1.73 m²/年相比，HR为3.86；95% CI：2.34 - 6.38）、低基线eGFR（15 - 19与25 - 29 ml/min/1.73 m²相比，HR为2.92；95% CI：1.61 - 5.30）以及低血红蛋白（血红蛋白<10 g/dl与>12 g/dl相比，HR为3.16；95% CI：1.64 - 6.08）。出院至初级保健的98例（24.7%）患者肾功能比仍接受肾脏病护理的患者更稳定（eGFR的中位数变化为+0.20与 - 1.88 ml/min/1.73 m²/年，P = 0.0001）。
大多数4期CKD患者，尤其是老年患者，未开始RRT就死亡。可以识别出进展风险低的患者，并通过积极的管理计划安全地将其出院至初级保健。
