慢性心力衰竭中的蛋白尿：患病率及预后重要性

Albuminuria in chronic heart failure: prevalence and prognostic importance.

作者信息

Jackson Colette E, Solomon Scott D, Gerstein Hertzel C, Zetterstrand Sofia, Olofsson Bertil, Michelson Eric L, Granger Christopher B, Swedberg Karl, Pfeffer Marc A, Yusuf Salim, McMurray John J V

机构信息

British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.

出版信息

Lancet. 2009 Aug 15;374(9689):543-50. doi: 10.1016/S0140-6736(09)61378-7.

DOI:10.1016/S0140-6736(09)61378-7

PMID:19683640

Abstract

BACKGROUND

Increased excretion of albumin in urine might be a marker of the various pathophysiological changes that arise in patients with heart failure. Therefore our aim was to assess the prevalence and prognostic value of a spot urinary albumin to creatinine ratio (UACR) in patients with heart failure.

METHODS

UACR was measured at baseline and during follow-up of 2310 patients in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Programme. The prevalence of microalbuminuria and macroalbuminuria, and the predictive value of UACR for the primary composite outcome of each CHARM study--ie, death from cardiovascular causes or admission to hospital with worsening heart failure--and death from any cause were assessed.

FINDINGS

1349 (58%) patients had a normal UACR, 704 (30%) had microalbuminuria, and 257 (11%) had macroalbuminuria. The prevalence of increased UACR was similar in patients with reduced and preserved left ventricular ejection fractions. Patients with an increased UACR were older, had more cardiovascular comorbidity, worse renal function, and a higher prevalence of diabetes mellitus than did those with normoalbuminuria. However, a high prevalence of increased UACR was still noted among patients without diabetes, hypertension, or renal dysfunction. Elevated UACR was associated with increased risk of the composite outcome and death even after adjustment for other prognostic variables including renal function, diabetes, and haemoglobin A1c. The adjusted hazard ratio (HR) for the composite outcome in patients with microalbuminuria versus normoalbuminuria was 1.43 (95% CI 1.21-1.69; p<0.0001) and for macroalbuminuria versus normoalbuminuria was 1.75 (1.39-2.20; p<0.0001). The adjusted values for death were 1.62 (1.32-1.99; p<0.0001) for microalbuminuria versus normoalbuminuria, and 1.76 (1.32-2.35; p=0.0001) for macroalbuminuria versus normoalbuminuria. Treatment with candesartan did not reduce or prevent the development of excessive excretion of urinary albumin.

INTERPRETATION

Increased UACR is a powerful and independent predictor of prognosis in heart failure.

FUNDING

AstraZeneca.

摘要

背景

尿中白蛋白排泄增加可能是心力衰竭患者出现的各种病理生理变化的一个标志物。因此，我们的目的是评估心力衰竭患者即时尿白蛋白与肌酐比值（UACR）的患病率及预后价值。

方法

在心力衰竭坎地沙坦：降低死亡率和发病率评估（CHARM）研究项目中，对2310例患者在基线期及随访期间测量UACR。评估微量白蛋白尿和大量白蛋白尿的患病率，以及UACR对各CHARM研究的主要复合结局（即心血管原因死亡或因心力衰竭恶化住院）和任何原因死亡的预测价值。

结果

1349例（58%）患者UACR正常，704例（30%）有微量白蛋白尿，257例（11%）有大量白蛋白尿。左心室射血分数降低和保留的患者中UACR升高的患病率相似。UACR升高的患者比正常白蛋白尿患者年龄更大，有更多的心血管合并症，肾功能更差，糖尿病患病率更高。然而，在没有糖尿病、高血压或肾功能不全的患者中仍发现UACR升高的患病率较高。即使在对包括肾功能、糖尿病和糖化血红蛋白等其他预后变量进行校正后，UACR升高仍与复合结局和死亡风险增加相关。微量白蛋白尿患者与正常白蛋白尿患者相比，复合结局的校正风险比（HR）为1.43（95%CI 1.21-1.69；p<0.0001），大量白蛋白尿患者与正常白蛋白尿患者相比为1.75（1.39-2.20；p<0.0001）。微量白蛋白尿患者与正常白蛋白尿患者相比，死亡的校正值为1.62（1.32-1.99；p<0.0001），大量白蛋白尿患者与正常白蛋白尿患者相比为1.76（1.32-2.35；p=0.0001）。坎地沙坦治疗并未降低或预防尿白蛋白过度排泄的发生。