基于标准化肌酐和胱抑素 C 的肾小球滤过率估计：老年人的欧洲多中心分析。
GFR estimation based on standardized creatinine and cystatin C: a European multicenter analysis in older adults.
机构信息
Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden.
出版信息
Clin Chem Lab Med. 2018 Feb 23;56(3):422-435. doi: 10.1515/cclm-2017-0563.
BACKGROUND
Although recommended by the Kidney Disease Improving Global Outcomes, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPICR) creatinine equation was not targeted to estimate glomerular filtration rate (eGFR) among older adults. The Berlin Initiative Study (BIS1CR) equation was specifically developed in older adults, and the Lund-Malmö revised (LMRCR) and the Full Age Spectrum (FASCR) equations have shown promising results in older adults. Our aim was to validate these four creatinine equations, including addition of cystatin C in a large multicenter cohort of Europeans ≥70 years.
METHODS
A total of 3226 individuals (2638 with cystatin C) underwent GFR measurement (mGFR; median, 44 mL/min/1.73 m2) using plasma iohexol clearance. Bias, precision (interquartile range [IQR]), accuracy (percent of estimates ±30% of mGFR, P30), eGFR accuracy diagrams and probability diagrams to classify mGFR<45 mL/min/1.73 m2 were compared.
RESULTS
The overall results of BIS1CR/CKD-EPICR/FASCR/LMRCR were as follows: median bias, 1.7/3.6/0.6/-0.7 mL/min/1.73 m2; IQR, 11.6/12.3/11.1/10.5 mL/min/1.73 m2; and P30, 77.5%/76.4%/80.9%/83.5% (significantly higher for LMR, p<0.001). Substandard P30 (<75%) was noted for all equations at mGFR<30 mL/min/1.73 m2, and at body mass index values <20 and ≥35 kg/m2. LMRCR had the most stable performance across mGFR subgroups. Only LMRCR and FASCR had a relatively constant small bias across eGFR levels. Probability diagrams exhibited wide eGFR intervals for all equations where mGFR<45 could not be confidently ruled in or out. Adding cystatin C improved P30 accuracy to 85.7/86.8/85.7/88.7 for BIS2CR+CYS/CKD-EPICR+CYS/FASCR+CYS/MEANLMR+CAPA.
CONCLUSIONS
LMRCR and FASCR seem to be attractive alternatives to CKD-EPICR in estimating GFR by creatinine-based equations in older Europeans. Addition of cystatin C leads to important improvement in estimation performance.
背景
尽管肾脏病预后质量倡议（Kidney Disease Improving Global Outcomes，KDIGO）推荐使用慢性肾脏病流行病学合作（Chronic Kidney Disease Epidemiology collaboration，CKD-EPIC）肌酐方程来估算肾小球滤过率（glomerular filtration rate，eGFR），但该方程并非针对老年人设计。柏林倡议研究（Berlin Initiative Study，BIS1CR）方程是专门为老年人开发的，而 Lund-Malmö 修订版（Lund-Malmö revised，LMRCR）和全年龄谱（Full Age Spectrum，FASCR）方程在老年人中显示出了良好的结果。我们的目的是在一个大型的欧洲≥70 岁多中心队列中验证这四个肌酐方程，包括在方程中加入胱抑素 C。
方法
共有 3226 名个体（2638 名个体检测了胱抑素 C）接受了使用血浆碘海醇清除率测量的肾小球滤过率（GFR；中位数为 44 ml/min/1.73 m2）。比较了 BIS1CR/CKD-EPICR/FASCR/LMRCR 这四个方程的偏倚、精度（四分位距 [interquartile range，IQR]）、准确性（估计值与 mGFR 的 30%的差异百分比，P30）、eGFR 准确性图和用于分类 mGFR<45 ml/min/1.73 m2 的概率图。
结果
BIS1CR/CKD-EPICR/FASCR/LMRCR 的总体结果如下：中位数偏倚分别为 1.7/3.6/0.6/-0.7 ml/min/1.73 m2；IQR 分别为 11.6/12.3/11.1/10.5 ml/min/1.73 m2；P30 分别为 77.5%/76.4%/80.9%/83.5%（LMR 显著更高，p<0.001）。所有方程在 mGFR<30 ml/min/1.73 m2 时 P30 均低于 75%，在 BMI<20 和≥35 kg/m2 时也如此。LMRCR 在各 GFR 亚组中的性能最稳定。只有 LMRCR 和 FASCR 在整个 eGFR 水平上具有相对稳定的小偏倚。概率图显示，对于所有方程，eGFR 水平的范围较宽，以至于 mGFR<45 不能被有信心地判定为存在或不存在。加入胱抑素 C 可将 BIS2CR+CYS/CKD-EPICR+CYS/FASCR+CYS/MEANLMR+CAPA 的 P30 准确性提高到 85.7/86.8/85.7/88.7。
结论
在估计欧洲老年人的 GFR 时，LMRCR 和 FASCR 似乎是 CKD-EPICR 的有吸引力的替代方案。加入胱抑素 C 可显著提高估算性能。
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