心房颤动患者肾功能的序贯变化以及中风和死亡风险
Sequential changes in renal function and the risk of stroke and death in patients with atrial fibrillation.
作者信息
Guo Yutao, Wang Haijun, Zhao Xiaoning, Zhang Yu, Zhang Dexian, Ma Jingling, Wang Yutang, Lip Gregory Y H
机构信息
University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom; Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China.
出版信息
Int J Cardiol. 2013 Oct 12;168(5):4678-84. doi: 10.1016/j.ijcard.2013.07.179. Epub 2013 Jul 30.
BACKGROUND
Renal dysfunction has been proposed for the risk factor for stroke and bleeding in atrial fibrillation (AF). The impact of changes in renal dysfunction over time and the relationship to stroke and bleeding risk in these patients remain unknown. We investigated sequential change in renal function (estimated glomerular filtration rate, eGFR) and the risk for clinical events (ischaemic stroke, death and major bleeding) over time in a cohort of 617 AF patients followed up for 2 years.
METHODS
eGFR was estimated at baseline, 6 months and 12 months using three formulas (Modification of Diet in Renal Disease equation, MDRD, Chronic Kidney Disease Epidemiology Collaboration, CKD-EPI, and Cockcroft-Gault equation). Changes in eGFR and the risk for clinical events were analysed by Cox models, receiver operating curves (ROC), and Kaplan-Meier survival curves.
RESULTS
When patients with eGFR≤60 ml/min/1.73 m(2) were compared to patients with eGFR>60 ml/min/1.73 m(2), there was an increase over time in stroke or death, or death, with impaired renal function (all p<0.05). An absolute decrease in eGFR≥15 ml/min/1.73 m(2) on Cockcroft-Gault and CKD-EPI and ≥25 ml/min/1.73 m(2) on MDRD were associated with an increased risk for stroke or death, death, and ischaemic stroke at 6 months (all p<0.05), but not major bleeding. A relative reduction (decline of ≥25%) in eGFR was also an independent risk. ROC analysis showed that a relative reduction in eGFR ≥25% at 6 months and 12 months modestly predicted the occurrence of stroke or death in patients with AF (c-indexes: 0.57 to 0.61, p<0.05).
CONCLUSION
In patients with AF, an absolute decrease in eGFR ≥15 ml/min/1.73 m(2) on Cockcroft-Gault and CKD-EPI, and ≥25 ml/min/1.73 m(2) on MDRD, or a relative reduction (≥25%) in eGFR, independently predicted the risk for the endpoints 'stroke or death', 'death' or (at 6 months) ischaemic stroke. Deteriorating renal function increases the risk of death in AF patients.
背景
肾功能不全被认为是心房颤动（AF）患者发生中风和出血的危险因素。肾功能不全随时间的变化及其与这些患者中风和出血风险的关系尚不清楚。我们在一个对617例AF患者进行了2年随访的队列中，研究了肾功能（估算肾小球滤过率，eGFR）的连续变化以及随时间发生临床事件（缺血性中风、死亡和大出血）的风险。
方法
使用三种公式（肾脏病饮食改良公式，MDRD；慢性肾脏病流行病学合作公式，CKD-EPI；以及Cockcroft-Gault公式）在基线、6个月和12个月时估算eGFR。通过Cox模型、受试者工作特征曲线（ROC）和Kaplan-Meier生存曲线分析eGFR的变化和临床事件的风险。
结果
将eGFR≤60 ml/min/1.73 m²的患者与eGFR>60 ml/min/1.73 m²的患者进行比较时，肾功能受损的患者中风或死亡、或死亡的发生率随时间增加（所有p<0.05）。Cockcroft-Gault公式和CKD-EPI公式计算的eGFR绝对降低≥15 ml/min/1.73 m²以及MDRD公式计算的≥25 ml/min/1.73 m²与6个月时中风或死亡、死亡和缺血性中风风险增加相关（所有p<0.05），但与大出血无关。eGFR相对降低（下降≥25%）也是一个独立风险因素。ROC分析表明，6个月和12个月时eGFR相对降低≥25%可适度预测AF患者中风或死亡的发生（c指数：0.57至0.61，p<0.05）。
结论
在AF患者中，Cockcroft-Gault公式和CKD-EPI公式计算的eGFR绝对降低≥15 ml/min/1.73 m²以及MDRD公式计算的≥25 ml/min/1.73 m²，或eGFR相对降低（≥25%），可独立预测“中风或死亡”、“死亡”或（6个月时）缺血性中风等终点事件的风险。肾功能恶化会增加AF患者的死亡风险。
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