Bezinque Adam, Parker Jessica, Babitz Stephen K, Noyes Sabrina L, Hu Susie, Lane Brian R
Michigan State University College of Osteopathic Medicine, East Lansing, MI, 48824, USA.
Spectrum Health Hospital System, Grand Rapids, MI, 49503, USA.
Ann Med Surg (Lond). 2019 Aug 1;45:120-126. doi: 10.1016/j.amsu.2019.07.029. eCollection 2019 Sep.
Chronic kidney disease (CKD) staging is improved by adding proteinuria to glomerular filtration rate (GFR). While proteinuria independently predicts CKD progression and mortality, the clinical setting of proteinuria determination has not been well-studied previously. The objective of our study is to determine whether clinical setting differentially impacts survival outcomes.
Kaplan-Meier and Cox proportional hazards analyses of overall survival were performed retrospectively for cohorts of outpatients (n = 22,918), emergency patients (n = 16,861), and inpatients (n = 12,304) subjected to urinalysis (UA) at a single health system in 2010. GFR (G1-G5) and proteinuria (A1:<30 mg, A2:30-300 mg, A3:>300 mg) were classified under Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.
GFR and proteinuria levels varied more in inpatients than in emergency and outpatients. For each clinical population, survival significantly decreased with increasing proteinuria (A1>A2>A3, p < 0.05 for each comparison). The effect of proteinuria on survival differed by clinical setting, with statistical differences in all categories other than A3 in outpatients and emergency patients (p = 0.98). The strongest predictors of mortality were cancer diagnosis (HR: 3.07, p < 0.0001) and very-high KDIGO classification (HR: 2.01, p < 0.0001). Limitations include the retrospective observational study design and single health system analysis.
The value of UA to screen for proteinuria in each clinical setting is evident, but the impact of A2 and A3 level proteinuria on survival varies depending on the clinical scenario in which the determination was made. The clinical setting of proteinuria measurement should be factored into both patient care and clinical research activities.
通过在肾小球滤过率（GFR）基础上增加蛋白尿指标，慢性肾脏病（CKD）的分期得到了改进。虽然蛋白尿可独立预测CKD的进展和死亡率，但此前蛋白尿测定的临床背景尚未得到充分研究。我们研究的目的是确定临床背景是否对生存结局有不同影响。
对2010年在单一医疗系统接受尿液分析（UA）的门诊患者队列（n = 22,918）、急诊患者队列（n = 16,861）和住院患者队列（n = 12,304）进行总体生存的Kaplan-Meier分析和Cox比例风险分析。GFR（G1 - G5）和蛋白尿（A1：<30mg，A2：30 - 300mg，A3：>300mg）根据肾脏病：改善全球预后（KDIGO）指南进行分类。
住院患者的GFR和蛋白尿水平变化比急诊患者和门诊患者更大。对于每个临床群体，随着蛋白尿增加，生存率显著降低（A1>A2>A3，每次比较p < 0.05）。蛋白尿对生存的影响因临床背景而异，门诊患者和急诊患者中除A3外的所有类别均有统计学差异（p = 0.98）。死亡率的最强预测因素是癌症诊断（HR：3.07，p < 0.0001）和极高的KDIGO分级（HR：2.01，p < 0.0001）。局限性包括回顾性观察性研究设计和单一医疗系统分析。
UA在每种临床背景下筛查蛋白尿的价值是明显的，但A2和A3级蛋白尿对生存的影响因进行测定的临床情况而异。蛋白尿测量的临床背景应纳入患者护理和临床研究活动中。
