Fogelfeld Leon, Hart Peter, Miernik Jadwiga, Ko Jocelyn, Calvin Donna, Tahsin Bettina, Adhami Anwar, Mehrotra Rajeev, Fogg Louis
Division of Endocrinology, Cook County Health & Hospitals System, Chicago, IL.
Division of Nephrology, Cook County Health & Hospitals System, Chicago, IL.
J Diabetes Complications. 2017 Mar;31(3):624-630. doi: 10.1016/j.jdiacomp.2016.11.019. Epub 2016 Dec 8.
To evaluate efficacy of a multifactorial-multidisciplinary approach in delaying CKD 3-4 progression to ESRD.
Two-year proof-of-concept stratified randomized control trial conducted in an outpatient clinic of a large public hospital system. This intervention, led by a team of endocrinologists, nephrologists, nurse practitioners, and registered dietitians, integrated intensive diabetes-renal care with behavioral/dietary and pharmacological interventions. 120 low-income adults with T2DM and CKD 3-4 enrolled; 58% male, 55% African American, 23% Hispanic.
Primary outcome was progression rate from CKD 3-4 to ESRD. Fewer intervention (13%) than control (28%) developed ESRD, p<0.05. Intervention had greater albumin/creatinine ratio (ACR) decrease (62% vs. 42%, p<0.05) and A1C<7% attainment (50% vs. 30%, p<0.05) and trended toward better lipid/blood pressure control (p=NS). Significant differences between 25 ESRD and 95 ESRD-free patients were baseline eGFR (28 vs. 40ml/min/1.73m), annual eGFR decline (15 vs. 3ml/min/year), baseline ACR (2362 vs. 1139mg/g), final ACR (2896 vs. 1201mg/g), and final A1C (6.9 vs. 7.8%). In multivariate Cox analysis, receiving the intervention reduced hazard ratio to develop ESRD (0.125, CI 0.029-0.54) as did higher baseline eGFR (0.69, CI 0.59-0.80). Greater annual eGFR decline increased hazard ratio (1.59, CI 1.34-1.87).
The intervention delayed ESRD. Improved A1C and ACR plus not-yet-identified variables may have influenced better outcomes. Multifactorial-multidisciplinary care may serve as a CKD 3-4 treatment paradigm.
评估多因素-多学科方法在延缓慢性肾脏病3-4期进展至终末期肾病方面的疗效。
在一家大型公立医院系统的门诊进行了为期两年的概念验证分层随机对照试验。该干预由内分泌科医生、肾病科医生、执业护士和注册营养师团队主导，将强化糖尿病-肾脏护理与行为/饮食及药物干预相结合。纳入了120名患有2型糖尿病和慢性肾脏病3-4期的低收入成年人；其中58%为男性，55%为非裔美国人，23%为西班牙裔。
主要结局是从慢性肾脏病3-4期进展至终末期肾病的发生率。进展至终末期肾病的干预组患者（13%）少于对照组（28%），p<0.05。干预组的白蛋白/肌酐比值（ACR）下降幅度更大（62%对42%，p<0.05），糖化血红蛋白（A1C）<7%的达标率更高（50%对30%，p<0.05），且在血脂/血压控制方面有更好的趋势（p=无显著差异）。25名进展至终末期肾病的患者与95名未进展至终末期肾病的患者之间的显著差异在于基线估算肾小球滤过率（eGFR）（28对40ml/min/1.73m²）、每年eGFR下降幅度（15对3ml/min/年）、基线ACR（2362对1139mg/g）、最终ACR（2896对1201mg/g）以及最终A1C（6.9对7.8%）。在多变量Cox分析中，接受干预可降低进展至终末期肾病的风险比（0.125，可信区间0.029-0.54），较高的基线eGFR也有同样作用（0.69，可信区间0.59-0.80）。每年更大的eGFR下降幅度会增加风险比（1.59，可信区间1.34-1.87）。
该干预延缓了终末期肾病的发生。A1C和ACR的改善以及尚未明确的变量可能对更好的结局产生了影响。多因素-多学科护理可作为慢性肾脏病3-4期的治疗模式。
