Hospital General de Segovia, 40002 Segovia, Spain.
Nefrologia. 2012 May 14;32(3):300-5. doi: 10.3265/Nefrologia.pre2012.Jan.10994. Epub 2012 Feb 28.
In recent years, chronic kidney disease (CKD) has come to be considered an epidemic problem, and there is considerable interest in early diagnosis in order to slow its progression to end-stage renal disease (ESRD) and prepare patients for dialysis and transplantation programmes. Many elderly patients are labelled as having CKD based solely on having a glomerular filtration rate (GFR) of <60 ml/min.
Monitor renal function (RF) and outcomes associated with CKD (morbidity, mortality and progress to ESRD) in an elderly cohort.
A total of 80 clinically stable patients, with a median age of 83 years (range 69-97; 69% female, 35% diabetic, 83% hypertensive) were recruited at random in our Geriatric Medicine and Nephrology Departments between January and April 2006, and monitored for 5 years. During the recruitment stage we established two groups based on baseline serum creatinine (SCr) concentration: Group 1, 38 patients with SCr <1.1mg/dl (range 0.7-1.1) and Group 2, 42 patients with SCr >1.1mg/dl (range 1.2-3). We determined baseline blood levels of creatinine and urea, calculated eGFR using an abbreviated Modification of Diet in Renal Disease (MDRD) formula, and repeated these measurements after 5 years. We recorded baseline comorbidity according to the Charlson comorbidity index (CCI); hospital admissions; new cardiovascular events; treatments; progression to ESRD requiring dialysis; and mortality.
In the 39 patients surviving after 5 years there were no significant differences between Groups 1 and 2 in total number of hospital admissions, episodes of heart failure and new ischaemic heart disease. Overall, the most commonly used drugs were diuretics (76.9%), while beta-blockers were used the least (10.3%). There were 41 deaths (51.3%): of these patients, 15 died due to overall decline, 8 due to infections, 4 due to stroke, 4 due to neoplasia, 3 due to cardiovascular problems, 2 due to complications from fractures and 5 due to unknown causes. Mortality was higher in Group 2 (66.7% vs 34.2%, P=.004) and patient age was also higher in that group (84.73 ± 5.69 vs 80.12 ± 6.5, P=.001). No significant differences in mortality were attributable to sex, diabetes, hypertension or CCI. Only 2 patients in Group 2 progressed to ESRD, they received conservative treatment due to comorbidity (no patients in the study have started dialysis). The evolution of RF (baseline/5 years) in all patients surviving at 5 years was as follows: SCr (mg/dl): 1.15 ± 0.41/1.21 ± 0.49 (not significant [NS]), urea (mg/dl) 52.21 ± 13.0/61.21 ± 27.0 (P=.047), MDRD (ml/min/1.73m2) 57.47 ± 15/54.86 ± 17 (NS). There were no differences in progression between the 2 groups. In the logistic regression analysis for overall mortality (independent variables: age, sex, CCI, cardiovascular history, SCr and group), only age (relative risk [RR]: 1.12; 1.03-1.23, P=.009) and group (RR: 3.06; 1.10-8.40, P=.031) were independently associated with mortality.
Screening for CKD using GFR only may lack clinical relevance in this population since RF slowly deteriorates in elderly patients without proteinuria. Mortality due to all causes was higher in elderly patients with a poorer baseline RF, and mortality rates were higher than rates of CKD progression to ESRD.
近年来，慢性肾脏病（CKD）已被认为是一种流行问题，人们对早期诊断非常感兴趣，以便减缓其向终末期肾病（ESRD）的进展，并为患者准备透析和移植计划。许多老年患者仅根据肾小球滤过率（GFR）<60ml/min 就被诊断为 CKD。
监测老年患者的肾功能（RF）和与 CKD 相关的结局（发病率、死亡率和进展为 ESRD）。
2006 年 1 月至 4 月期间，我们在老年医学和肾脏病科随机招募了 80 名临床稳定的患者，中位年龄为 83 岁（范围 69-97 岁；69%为女性，35%为糖尿病患者，83%为高血压患者），并进行了 5 年的监测。在招募阶段，我们根据基线血清肌酐（SCr）浓度将患者分为两组：第 1 组 38 例患者的 SCr<1.1mg/dl（范围 0.7-1.1），第 2 组 42 例患者的 SCr>1.1mg/dl（范围 1.2-3）。我们测定了基线血肌酐和尿素水平，使用简化肾脏病饮食改良公式（MDRD）计算了 eGFR，并在 5 年后重复这些测量。我们根据 Charlson 合并症指数（CCI）记录了基线合并症；住院治疗；新发心血管事件；治疗；需要透析的 ESRD 进展；以及死亡率。
在 5 年后存活的 39 名患者中，第 1 组和第 2 组在总住院次数、心力衰竭发作和新发缺血性心脏病方面没有显著差异。总体而言，最常用的药物是利尿剂（76.9%），而β受体阻滞剂使用最少（10.3%）。共有 41 例死亡（51.3%）：其中 15 例因整体健康状况下降而死亡，8 例因感染而死亡，4 例因中风而死亡，4 例因肿瘤而死亡，3 例因心血管问题而死亡，2 例因骨折并发症而死亡，5 例因不明原因而死亡。第 2 组的死亡率更高（66.7%比 34.2%，P=.004），而且该组的患者年龄也更高（84.73±5.69 比 80.12±6.5，P=.001）。性别、糖尿病、高血压或 CCI 与死亡率无显著差异。第 2 组仅 2 例患者进展为 ESRD，由于合并症（研究中没有患者开始透析），他们接受了保守治疗。所有在 5 年后存活的患者的 RF （基线/5 年）演变如下：SCr（mg/dl）：1.15±0.41/1.21±0.49（无显著差异[NS]），尿素（mg/dl）：52.21±13.0/61.21±27.0（P=.047），MDRD（ml/min/1.73m2）：57.47±15/54.86±17（NS）。两组之间无进展差异。在总死亡率的逻辑回归分析（独立变量：年龄、性别、CCI、心血管病史、SCr 和组）中，只有年龄（相对风险[RR]：1.12；1.03-1.23，P=.009）和组（RR：3.06；1.10-8.40，P=.031）与死亡率独立相关。
在该人群中，仅使用 GFR 筛查 CKD 可能缺乏临床意义，因为老年患者的 RF 会缓慢恶化而无蛋白尿。基线 RF 较差的老年患者的全因死亡率更高，死亡率高于 CKD 进展为 ESRD 的比率。
