肾小球滤过率特异界值可提高循环心脏生物标志物在晚期慢性肾脏病中的预后价值。

Glomerular Filtration Rate-Specific Cutoffs Can Refine the Prognostic Value of Circulating Cardiac Biomarkers in Advanced Chronic Kidney Disease.

机构信息

Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; BC Renal, Vancouver, British Columbia, Canada.

Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada.

出版信息

Can J Cardiol. 2019 Sep;35(9):1106-1113. doi: 10.1016/j.cjca.2019.06.014. Epub 2019 Jun 21.

DOI:10.1016/j.cjca.2019.06.014

PMID:31472810

Abstract

BACKGROUND

Using standard cutoffs derived from healthy adults, high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are frequently elevated in patients with reduced glomerular filtration rate (GFR), with unclear implications. We sought to compare GFR-specific cutoffs of each biomarker with standard cutoffs for discrimination of cardiovascular risk in asymptomatic patients with chronic kidney disease.

METHODS

We investigated a prospective cohort of 1956 participants with median GFR of 27 mL/min/1.73 m. Cox proportional hazards models were used to examine the association between each biomarker and first adjudicated cardiovascular event (unstable angina, myocardial infarction, heart failure, stroke, cardiovascular death). We used an outcome-based approach to identify optimal risk-based cutoffs for each biomarker within GFR strata (< 20, 20-29, 30-44 mL/min/1.73 m). We evaluated the added prognostic value of each biomarker to a multivariable base model, comparing GFR-specific with standard cutoffs.

RESULTS

Hs-cTnT and NT-proBNP were elevated in 76% and 82% of participants, respectively. A total of 401 events were recorded during 6772 person-years at risk. Both biomarkers were independent predictors of cardiovascular events. Optimal cutoffs for each biomarker were higher than standard thresholds, being highest at GFR values < 20 mL/min/1.73 m. Addition of hs-cTnT to the base model using GFR-specific cutoffs significantly improved reclassification for events (52%) and nonevents (21%). Similar findings were observed for NT-proBNP. In contrast, use of standard cutoffs failed to reclassify patients who had no event as lower risk.

CONCLUSIONS

Among asymptomatic patients with advanced chronic kidney disease, optimal cutoffs for hs-cTnT and NT-proBNP differed according to GFR level and outperformed standard cutoffs for discrimination of cardiovascular risk.

摘要

背景

使用源于健康成年人的标准截止值，高敏心肌肌钙蛋白 T（hs-cTnT）和 N 末端 pro-B 型利钠肽（NT-proBNP）在肾小球滤过率（GFR）降低的患者中经常升高，其含义尚不清楚。我们旨在比较每个生物标志物的 GFR 特异性截止值与标准截止值，以区分无症状慢性肾脏病患者的心血管风险。

方法

我们研究了一个前瞻性队列，共有 1956 名患者的中位 GFR 为 27 mL/min/1.73 m。Cox 比例风险模型用于研究每个生物标志物与首次裁决的心血管事件（不稳定型心绞痛、心肌梗死、心力衰竭、中风、心血管死亡）之间的关联。我们采用基于结果的方法，在 GFR 分层（<20、20-29、30-44 mL/min/1.73 m）内为每个生物标志物确定最佳基于风险的截止值。我们评估了每个生物标志物对多变量基础模型的额外预后价值，比较了 GFR 特异性截止值与标准截止值。

结果

hs-cTnT 和 NT-proBNP 分别在 76%和 82%的患者中升高。在 6772 人年的风险期间共记录了 401 例事件。两个生物标志物都是心血管事件的独立预测因子。每个生物标志物的最佳截止值均高于标准阈值，在 GFR 值<20 mL/min/1.73 m 时最高。使用 GFR 特异性截止值将 hs-cTnT 添加到基础模型中，可显著提高事件（52%）和非事件（21%）的再分类。NT-proBNP 也观察到类似的发现。相比之下，使用标准截止值无法将没有事件的患者重新分类为低风险。