Pediatric Nephrology Unit, Department of Pediatrics, Bordeaux University Hospital, and Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team LEHA, UMR 1219, Bordeaux, France.
Institute for Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany.
Kidney Int. 2017 Dec;92(6):1507-1514. doi: 10.1016/j.kint.2017.05.006. Epub 2017 Jul 18.
Recent studies in adult chronic kidney disease (CKD) suggest that metabolic acidosis is associated with faster decline in estimated glomerular filtration rate (eGFR). Alkali therapies improve the course of kidney disease. Here we investigated the prevalence and determinants of abnormal serum bicarbonate values and whether metabolic acidosis may be deleterious to children with CKD. Associations between follow-up serum bicarbonate levels categorized as under 18, 18 to under 22, and 22 or more mmol/l and CKD outcomes in 704 children in the Cardiovascular Comorbidity in Children with CKD Study, a prospective cohort of pediatric patients with CKD stages 3-5, were studied. The eGFR and serum bicarbonate were measured every six months. At baseline, the median eGFR was 27 ml/min/1.73m and median serum bicarbonate level 21 mmol/l. During a median follow-up of 3.3 years, the prevalence of metabolic acidosis (serum bicarbonate under 22 mmol/l) was 43%, 60%, and 45% in CKD stages 3, 4, and 5, respectively. In multivariable analysis, the presence of metabolic acidosis as a time-varying covariate was significantly associated with log serum parathyroid hormone through the entire follow-up, but no association with longitudinal growth was found. A total of 211 patients reached the composite endpoint (ESRD or 50% decline in eGFR). In a multivariable Cox model, children with time-varying serum bicarbonate under 18 mmol/l had a significantly higher risk of CKD progression compared to those with a serum bicarbonate of 22 or more mmol/l (adjusted hazard ratio 2.44; 95% confidence interval 1.43-4.15). Thus, metabolic acidosis is a common complication in pediatric patients with CKD and may be a risk factor for secondary hyperparathyroidism and kidney disease progression.
最近对成人慢性肾脏病（CKD）的研究表明，代谢性酸中毒与估计肾小球滤过率（eGFR）下降速度加快有关。碱疗法可改善肾脏疾病的进程。在这里，我们调查了异常血清碳酸氢盐值的患病率和决定因素，以及代谢性酸中毒是否可能对患有 CKD 的儿童有害。在心血管合并症在儿童 CKD 研究中，对 704 名处于 CKD 3-5 期的儿科患者前瞻性队列中的儿童进行了随访血清碳酸氢盐水平分为低于 18、18-低于 22 和 22 或更多 mmol/L 与 CKD 结局之间的相关性。每六个月测量一次 eGFR 和血清碳酸氢盐。在基线时，中位 eGFR 为 27ml/min/1.73m，中位血清碳酸氢盐水平为 21mmol/L。在中位随访 3.3 年期间，CKD 3 期、4 期和 5 期的代谢性酸中毒（血清碳酸氢盐低于 22mmol/L）的患病率分别为 43%、60%和 45%。在多变量分析中，作为时变协变量的代谢性酸中毒的存在与整个随访期间的血清甲状旁腺激素对数显著相关，但与纵向生长无关。共有 211 名患者达到了复合终点（ESRD 或 eGFR 下降 50%）。在多变量 Cox 模型中，与血清碳酸氢盐为 22mmol/L 或更高的儿童相比，血清碳酸氢盐随时间变化低于 18mmol/L 的儿童发生 CKD 进展的风险显著更高（调整后的危险比 2.44；95%置信区间 1.43-4.15）。因此，代谢性酸中毒是儿科 CKD 患者的常见并发症，可能是继发性甲状旁腺功能亢进和肾脏疾病进展的危险因素。
