Hepatology and Liver Intensive Care Unit, U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3.
Liver Transpl. 2010 Oct;16(10):1169-77. doi: 10.1002/lt.22128.
Renal function has a significant impact on early mortality in patients with cirrhosis. However, creatinine and creatinine-based equations are inaccurate markers of renal function in cirrhosis. The aim of this study was to reassess correlations between creatinine-based equations and measured glomerular filtration rate (GFR) and to investigate the impact of inaccuracies on the Model for End-Stage Liver Disease (MELD) score. GFR was measured using iohexol clearance and calculated with creatinine-based equations in 157 patients with cirrhosis during pretransplant evaluation. We compared the accuracy of creatinine to that of true GFR in a prognostic score also including bilirubin and the international normalized ratio. In patients with creatinine below 1 mg/dL, true GFR ranged from 34-163 mL/minute/1.73 m(2). Cockcroft and Modification of Diet in Renal Disease (MDRD) significantly overestimated true GFR. On multivariate analysis, younger age and ascites were significantly correlated with the overestimation of true GFR by 20% or more. Body mass index was an independent risk factor of overestimation of GFR with Cockcroft but not with MDRD. The accuracy of a prognostic score combining bilirubin, international normalized ratio, and true GFR was superior to that of MELD, whether creatinine was rounded to 1 mg/dL when lower than 1 mg/dL or not (c-statistic of 0.8 versus 0.75 and 0.73, respectively). Creatinine-based formulas overestimate true GFR, especially in patients younger than 50 years or with ascites. In patients with serum creatinine below 1 mg/dL, the spectrum of true GFR is large. True GFR seems to have a better prognostic value than creatinine and creatinine-based equations. Specific equations are needed in patients with cirrhosis to improve prognostic scores.
肾功能对肝硬化患者的早期死亡率有重大影响。然而，肌酐和基于肌酐的公式并不能准确反映肝硬化患者的肾功能。本研究旨在重新评估基于肌酐的公式与肾小球滤过率（GFR）之间的相关性，并研究不准确对终末期肝病模型（MELD）评分的影响。在移植前评估期间，我们使用 iohexol 清除率测量了 157 例肝硬化患者的 GFR，并使用基于肌酐的公式进行了计算。我们将肌酐的准确性与包括胆红素和国际标准化比值的预后评分中的真实 GFR 进行了比较。在肌酐低于 1mg/dL 的患者中，真实 GFR 范围为 34-163ml/min/1.73m(2)。Cockcroft 和改良肾脏病饮食法（MDRD）公式显著高估了真实 GFR。多变量分析显示，年龄较小和腹水与真实 GFR 被高估 20%或更多呈显著相关。体重指数是 Cockcroft 高估 GFR 的独立危险因素，但不是 MDRD 的危险因素。将胆红素、国际标准化比值和真实 GFR 结合起来的预后评分的准确性优于 MELD，无论肌酐低于 1mg/dL 时是否舍入到 1mg/dL（当肌酐低于 1mg/dL 时，其准确性为 0.8，而 MELD 为 0.75 和 0.73）。基于肌酐的公式高估了真实 GFR，尤其是在年龄小于 50 岁或有腹水的患者中。在血清肌酐低于 1mg/dL 的患者中，真实 GFR 的范围较大。真实 GFR 似乎比肌酐和基于肌酐的公式具有更好的预后价值。需要针对肝硬化患者制定特定的公式以改善预后评分。
