Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
JAMA. 2010 Feb 3;303(5):423-9. doi: 10.1001/jama.2010.39.
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.
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).
All-cause mortality, myocardial infarction, and progression to kidney failure.
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.
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.
慢性肾脏病的现行分期系统主要基于估算肾小球滤过率（eGFR），较低的 eGFR 与更高的不良结局风险相关。尽管蛋白尿也与不良结局相关，但在当前系统中，它并未用于细化不良事件的风险估计。
确定肾小球滤过率降低、蛋白尿与不良临床结局之间的关系。
设计、地点和参与者：一项基于社区的队列研究，参与者来自于艾伯塔省（加拿大）的全省范围实验室登记处，该登记处包括 2002 年至 2007 年间的 eGFR 和蛋白尿测量值。共有 920985 名成年人至少有 1 次门诊血清肌酐测量值，且基线时无需肾脏替代治疗。蛋白尿通过尿试纸或白蛋白-肌酐比（ACR）进行评估。
全因死亡率、心肌梗死和进展为肾衰竭。
大多数人（89.1%）的 eGFR 为 60 mL/min/1.73 m²或更高。在中位数为 35 个月（范围 0-59 个月）的随访期间，27959 名参与者（3.0%）死亡。在研究参与者中，较低的 eGFR 或较重的蛋白尿与更高的全因死亡率相关。与 eGFR 为 45 至 59.9 mL/min/1.73 m²且蛋白尿正常的个体相比，用尿试纸测量的大量蛋白尿且 eGFR 为 60 mL/min/1.73 m²或更高的个体的校正死亡率高出两倍以上（发生率分别为 7.2[95%CI,6.6-7.8]和 2.9[95%CI,2.7-3.0]/1000 人年；发生率比，2.5[95%CI,2.3-2.7]）。当蛋白尿通过 ACR 测量时（发生率分别为 15.9[95%CI,14.0-18.1]和 7.0[95%CI,6.4-7.6]/1000 人年），以及在因急性心肌梗死住院、终末期肾病和血清肌酐水平翻倍的结局中，也观察到了类似的结果。
在特定 eGFR 水平下，蛋白尿水平较高的患者的死亡率、心肌梗死和进展为肾衰竭风险独立增加。
