Coscas Raphael, Wagner Sandra, Vilaine Eve, Sartorius Albane, Javerliat Isabelle, Alvarez Jean Claude, Goeau-Brissonniere Olivier, Coggia Marc, Massy Ziad
Service de chirurgie vasculaire, Hôpital Ambroise Paré, APHP, Boulogne-Billancourt, France; INSERM U1018, CESP, UVSQ, Université Paris-Saclay, Villejuif, France.
INSERM U1018, CESP, UVSQ, Université Paris-Saclay, Villejuif, France; Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT) Network, Vandoeuvre-lès-Nancy, France.
Ann Vasc Surg. 2017 Apr;40:162-169. doi: 10.1016/j.avsg.2016.08.013. Epub 2016 Nov 24.
Chronic impaired renal function constitutes a major risk factor of morbi-mortality during the treatment of an abdominal aortic aneurism (AAA). The inflammatory state due to the AAA could result in a reduction in the muscular mass and an overestimation of the glomerular filtration rate (GFR) with the usual formulas. The objective of this study was to determine if the formulas used to evaluate the estimated GFR were adapted in patients with AAA.
Between August 2013 and November 2014, we conducted an exploratory study to evaluate the renal function before surgery for AAA in 28 patients. The renal function was evaluated by (1) the dosage of plasmatic creatinine, (2) the GFR estimated with the Cockroft-Gault, Modification of Diet in Renal Disease (MDRD), and chronic kidney disease epidemiology collaboration (CKD-EPI) formulas, (3) the creatinine clearance (CC), and (4) the direct measurement of the GFR with a reference method (iohexol clearance). Statistical analysis was carried out to compare and correlate the GFR estimated by the various formulas with the GFR measured by the reference technique.
The study included 21 men (75%) and 7 women (25%), with a median age of 76 years (58-89). The measured GFR was correlated with the GFR estimated from the CKD-EPI (rho = 0.78, P < 0.0001), the MDRD (rho = 0.78, P < 0.0001), the Cockroft-Gault (rho = 0.65, P = 0.0002), and CC (rho = 0.86, P < 0.0001). However, there were important individual variations between estimated and measured GFR. As regards the detection of the patients presenting a GFR <60 mL/min/1.73 m, the sensitivities of the CKD-EPI, MDRD, Cockroft-Gault formulas and CC were 64%, 64%, 71%, and 70%, respectively. Specificities were 71%, 79%, 57%, and 100%, respectively. The estimation of the GFR by the CKD-EPI formula had the lowest bias (-3.0). Bland-Altman plots indicated that the estimation of the GFR by the CKD-EPI formula had the best performance in comparison with the other methods.
This study found a statistical correlation between the measurement of the GFR and the various formulas available to estimation the GFR among AAA patients. The CKD-EPI formula is most appropriate. However, there were important individual variations between the measurement and the estimations of the GFR. A larger scale study is necessary to determine the profile of the patients with a risk of error in the estimation of the GFR. The French recommendations on the evaluation of the renal function before AAA treatment remain based on serum creatinine and should be revalued.
慢性肾功能损害是腹主动脉瘤（AAA）治疗期间发病和死亡的主要危险因素。AAA所致的炎症状态可能导致肌肉量减少，并且用常用公式会高估肾小球滤过率（GFR）。本研究的目的是确定用于评估估算GFR的公式是否适用于AAA患者。
在2013年8月至2014年11月期间，我们进行了一项探索性研究，以评估28例AAA患者手术前的肾功能。通过以下方式评估肾功能：（1）血浆肌酐测定；（2）用Cockcroft-Gault公式、肾脏病膳食改良（MDRD）公式和慢性肾脏病流行病学合作（CKD-EPI）公式估算GFR；（3）肌酐清除率（CC）；（4）用参考方法（碘海醇清除率）直接测量GFR。进行统计分析以比较各种公式估算的GFR与参考技术测量的GFR并进行相关性分析。
该研究纳入21名男性（75%）和7名女性（25%），中位年龄为76岁（58 - 89岁）。测量的GFR与CKD-EPI公式估算的GFR（rho = 0.78，P < 0.0001）、MDRD公式估算的GFR（rho = 0.78，P < 0.0001）、Cockcroft-Gault公式估算的GFR（rho = 0.65，P = 0.0002）和CC（rho = 0.86，P < 0.0001）相关。然而，估算的GFR与测量的GFR之间存在重要的个体差异。关于检测GFR <60 mL/min/1.73m²的患者，CKD-EPI公式、MDRD公式、Cockcroft-Gault公式和CC的敏感性分别为64%、64%、71%和70%。特异性分别为71%、79%、57%和100%。CKD-EPI公式估算的GFR偏差最低（-3.0）。Bland-Altman图表明，与其他方法相比，CKD-EPI公式估算GFR的性能最佳。
本研究发现AAA患者中GFR测量值与各种估算GFR的公式之间存在统计学相关性。CKD-EPI公式最为合适。然而，GFR的测量值与估算值之间存在重要的个体差异。需要进行更大规模的研究来确定GFR估算有误差风险的患者特征。法国关于AAA治疗前肾功能评估的建议仍基于血清肌酐，应重新评估。
