Dipartimento di Scienze della Salute dell’Università, Azienda Ospedaliera Universitaria San Martino, Genova, Italy.
Nephrol Dial Transplant. 2011 Feb;26(2):670-7. doi: 10.1093/ndt/gfq409. Epub 2010 Jul 13.
The role of cardiovascular factors in predicting renal outcome has not been extensively elucidated. Herein, we report a prospective evaluation of the impact of left ventricular hypertrophy (LVH) on outcome in non-diabetic patients with chronic kidney disease (CKD).
We studied 144 patients (99 men; age 62±14 years) with stage 3-4 CKD, with baseline assessment of left ventricular mass index (LVMi) by echocardiography, estimated glomerular filtration rate (eGFR) by MDRD equation, 24-h blood pressure profile and 24-h proteinuria. Combined end point was progression to ESRD requiring dialysis, or death within 5 years.
Forty-nine patients (34%) progressed to dialysis, 24 (17%) died, 57 (39%) were dialysis-free after 5 years and 14 were lost to follow-up. Multivariate Cox proportional hazards analysis showed that increased LVMi (HR 1.28, 95% CI 1.17-1.40 for each 10-g/m2 increase, P<0.0001) and reduced eGFR (5% risk increase for each 1-mL/min reduction, P=0.027) were the significant predictors of the combined end point in stage 3 CKD patients, whereas LVMi proved to be the only significant predictor of the combined end point in patients with stage 4 CKD (HR 1.19, 95% CI 1.09-1.31, P<0.0001). The same analysis showed that LVMi was the only significant predictor of progression to dialysis in stage 3 CKD patients (HR 1.42, 95% CI 1.23-1.64 for each 10-g/m2 increase, P<0.0001), while a 20% increase in the risk of progression to ESRD was observed for each 10-g/m2 increase in LVMi (P<0.0001), and a 10% increase for each 1-mL/min reduction in eGFR (P=0.046) in patients with stage 4 CKD. When evaluating the predictive role of LVMi on outcome using AUC-ROC curves, the overall performance of the model including LVMi (AUC 0.877, 95% CI 0.8-0.954) was superior to the model including eGFR (AUC 0.737, 95% CI 0.656-0.817) for the end point of progression to dialysis (P=0.026, Hanley test).
LVH proved to be the strongest predictor of the risk of progression to dialysis in non-diabetic CKD, especially among patients with less advanced renal dysfunction. Regardless of whether it is a simple marker or a pathogenetic factor, LVH encompasses all factors possibly affecting renal and general outcome in CKD patients.
心血管因素在预测肾脏结局方面的作用尚未得到充分阐明。在此，我们报告了一项前瞻性评估左心室肥厚（LVH）对非糖尿病慢性肾脏病（CKD）患者结局的影响。
我们研究了 144 名患者（99 名男性；年龄 62±14 岁），这些患者患有 3-4 期 CKD，基线时通过超声心动图评估左心室质量指数（LVMi），通过 MDRD 方程评估肾小球滤过率（eGFR），24 小时血压谱和 24 小时蛋白尿。联合终点为进展为需要透析的终末期肾病，或 5 年内死亡。
49 名患者（34%）进展为透析，24 名患者（17%）死亡，57 名患者（39%）在 5 年后无透析，14 名患者失访。多变量 Cox 比例风险分析显示，LVMi 增加（每增加 10g/m2，HR 为 1.28，95%CI 为 1.17-1.40，P<0.0001）和 eGFR 降低（每降低 1mL/min，风险增加 5%，P=0.027）是 3 期 CKD 患者联合终点的显著预测因素，而 LVMi 是 4 期 CKD 患者联合终点的唯一显著预测因素（HR 为 1.19，95%CI 为 1.09-1.31，P<0.0001）。同样的分析表明，LVMi 是 3 期 CKD 患者进展为透析的唯一显著预测因素（每增加 10g/m2，HR 为 1.42，95%CI 为 1.23-1.64，P<0.0001），而 LVMi 每增加 10g/m2，进展为 ESRD 的风险增加 20%（P<0.0001），eGFR 每降低 1mL/min，进展为 ESRD 的风险增加 10%（P=0.046）在 4 期 CKD 患者中。当使用 AUC-ROC 曲线评估 LVMi 对结局的预测作用时，包括 LVMi 的模型（AUC 0.877，95%CI 0.8-0.954）的整体性能优于包括 eGFR 的模型（AUC 0.737，95%CI 0.656-0.817），用于进展为透析的终点（P=0.026，Hanley 检验）。
LVH 被证明是非糖尿病 CKD 患者进展为透析的最强预测因素，尤其是在肾功能障碍程度较低的患者中。无论 LVMi 是简单的标志物还是致病因素，它都包含了可能影响 CKD 患者肾脏和整体结局的所有因素。
