Szummer Karolina, Evans Marie, Carrero Juan Jesus, Alehagen Urban, Dahlström Ulf, Benson Lina, Lund Lars H
Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
Open Heart. 2017 Jun 8;4(2):e000568. doi: 10.1136/openhrt-2016-000568. eCollection 2017.
It is unknown how the creatinine-based renal function estimations differ for dose adjustment cut-offs and risk prediction in patients with heart failure.
The renal function was similar with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (median 59 mL/min/1.73 m, IQR 42 to 77) and Modification of Diet in Renal Disease Study (MDRD) (59 mL/min/1.73 m, IQR 43 to 75) and slightly lower with the Cockcroft-Gault (CG) equation (57 mL/min, IQR 39 to 82). Across the commonly used renal function stages, the CKD-EPI and the MDRD classified patients into the same stage in 87.2% (kappa coefficient 0.83, p<0.001); the CKD-EPI and the CG equation agreed in 52.3% (kappa coefficient 0.39, p<0.001). Hence, a differing number of patients will receive dose adjustment depending on which formula is used as cut-off. The CG equation predicted worse prognosis better (c-statistics 0.740, 95% CI 0.734 to 0.746) than CKD-EPI (0.697, 95% CI 0.690 to 0.703, p<0.001) and MDRD (0.680, 95% CI 0.734 to 0.746). Using net reclassification improvement (NRI), the CG identified 12.8% more patients at higher risk of death as compared with the CKD-EPI equation. Patients registered in the Swedish Heart Failure Registry (n= 40 736) with standardised creatinine values between 2000 and 2012 had their renal function estimated with the CKD-EPI, the MDRD and the CG. Agreement between the formulas was compared for categories. Prediction of death was assessed with c-statistics and with NRI.
The choice of renal function estimation formula has clinical implications and differing results at various cut-off levels. For prognosis, the CG predicts mortality better than the CKD-EPI and MDRD.
目前尚不清楚基于肌酐的肾功能评估在心力衰竭患者的剂量调整临界值和风险预测方面有何不同。
慢性肾脏病流行病学协作组（CKD-EPI）公式估算的肾功能（中位数59 mL/min/1.73 m²，四分位间距42至77）与肾脏病膳食改良研究（MDRD）公式估算的结果相似（59 mL/min/1.73 m²，四分位间距43至75），而Cockcroft-Gault（CG）公式估算的结果略低（57 mL/min，四分位间距39至82）。在常用的肾功能分期中，CKD-EPI和MDRD将患者分到同一分期的比例为87.2%（kappa系数0.83，p<0.001）；CKD-EPI和CG公式的一致性为52.3%（kappa系数0.39，p<0.001）。因此，根据用作临界值的公式不同，接受剂量调整的患者数量也会不同。CG公式预测预后较差的能力优于CKD-EPI（c统计量0.740，95%可信区间0.734至0.746）和MDRD（0.680，95%可信区间0.734至0.746，p<0.001）。使用净重新分类改善率（NRI），与CKD-EPI公式相比，CG公式能多识别出12.8%死亡风险较高的患者。对2000年至2012年期间瑞典心力衰竭登记处登记的、肌酐值标准化的40736例患者，使用CKD-EPI、MDRD和CG公式估算其肾功能。比较各公式在不同类别中的一致性。用c统计量和NRI评估死亡预测情况。
肾功能评估公式的选择具有临床意义，且在不同临界值水平下结果不同。对于预后评估，CG公式预测死亡率的能力优于CKD-EPI和MDRD。
