Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, USA.
Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA.
BMC Nephrol. 2018 Jun 22;19(1):146. doi: 10.1186/s12882-018-0942-1.
Chronic kidney disease (CKD) is highly prevalent but identification of patients at high risk for fast CKD progression before reaching end-stage renal disease in the short-term has been challenging. Whether factors associated with fast progression vary by diabetes status is also not well understood. We examined a large community-based cohort of adults with CKD to identify predictors of fast progression during the first 2 years of follow-up in the presence or absence of diabetes mellitus.
Within a large integrated healthcare delivery system in northern California, we identified adults with estimated glomerular filtration rate (eGFR) 30-59 ml/min/1.73 m by CKD-EPI equation between 2008 and 2010 who had no previous dialysis or renal transplant, who had outpatient serum creatinine values spaced 10-14 months apart and who did not initiate renal replacement therapy, die or disenroll during the first 2 years of follow-up. Through 2012, we calculated the annual rate of change in eGFR and classified patients as fast progressors if they lost > 4 ml/min/1.73 m per year. We used multivariable logistic regression to identify patient characteristics that were independently associated with fast CKD progression stratified by diabetes status.
We identified 36,195 eligible adults with eGFR 30-59 ml/min/1.73 m and mean age 73 years, 55% women, 11% black, 12% Asian/Pacific Islander and 36% with diabetes mellitus. During 24-month follow-up, fast progression of CKD occurred in 23.0% of patients with diabetes vs. 15.3% of patients without diabetes. Multivariable predictors of fast CKD progression that were similar by diabetes status included proteinuria, age ≥ 80 years, heart failure, anemia and higher systolic blood pressure. Age 70-79 years, prior ischemic stroke, current or former smoking and lower HDL cholesterol level were also predictive in patients without diabetes, while age 18-49 years was additionally predictive in those with diabetes.
In a large, contemporary population of adults with eGFR 30-59 ml/min/1.73 m, accelerated progression of kidney dysfunction within 2 years affected ~ 1 in 4 patients with diabetes and ~ 1 in 7 without diabetes. Regardless of diabetes status, the strongest independent predictors of fast CKD progression included proteinuria, elevated systolic blood pressure, heart failure and anemia.
慢性肾脏病（CKD）发病率较高，但在短期内达到终末期肾病之前，识别出快速 CKD 进展风险高的患者一直具有挑战性。糖尿病患者和非糖尿病患者的快速进展相关因素是否存在差异，目前也不是很清楚。我们研究了一个大型的基于社区的 CKD 成年患者队列，以确定在有无糖尿病的情况下，在随访的头 2 年内快速进展的预测因素。
在加利福尼亚州北部的一个大型综合医疗服务系统中，我们通过 CKD-EPI 方程识别出 2008 年至 2010 年间 eGFR 为 30-59ml/min/1.73m 的成年人，这些患者之前没有接受过透析或肾移植，有门诊血清肌酐值，两次检查之间的时间间隔为 10-14 个月，且在随访的头 2 年内没有开始肾脏替代治疗、死亡或退出研究。截至 2012 年，我们计算了 eGFR 的年变化率，并将每年 eGFR 下降>4ml/min/1.73m 的患者定义为快速进展者。我们使用多变量逻辑回归来确定与快速 CKD 进展相关的患者特征，并按糖尿病状态进行分层。
我们确定了 36195 名 eGFR 为 30-59ml/min/1.73m、平均年龄为 73 岁的合格成年人，其中 55%为女性，11%为黑人，12%为亚裔/太平洋岛民，36%患有糖尿病。在 24 个月的随访中，糖尿病患者中有 23.0%的患者出现 CKD 快速进展，而非糖尿病患者中有 15.3%的患者出现 CKD 快速进展。按糖尿病状态分层，与快速 CKD 进展相关的多变量预测因素包括蛋白尿、年龄≥80 岁、心力衰竭、贫血和较高的收缩压。在没有糖尿病的患者中，年龄 70-79 岁、既往缺血性卒中、当前或曾经吸烟以及较低的高密度脂蛋白胆固醇水平也是预测因素，而在患有糖尿病的患者中，年龄 18-49 岁是另外一个预测因素。
在一个大型的、当代的 eGFR 为 30-59ml/min/1.73m 的成年患者队列中，2 年内肾功能恶化的加速进展影响了约 1/4 的糖尿病患者和 1/7 的非糖尿病患者。无论是否患有糖尿病，快速 CKD 进展的最强独立预测因素包括蛋白尿、较高的收缩压、心力衰竭和贫血。
