肾功能障碍对不明来源栓塞性卒中预后的影响：CHA2DS2-VASc 评分以外的作用：来自台湾卒中登记研究的结果。

Prognostic impact of renal dysfunction on embolic stroke of undetermined source-Role beyond CHA DS -VASc score: Results from Taiwan Stroke Registry.

机构信息

School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan.

Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.

出版信息

Eur J Neurol. 2021 Apr;28(4):1253-1264. doi: 10.1111/ene.14662. Epub 2020 Dec 22.

DOI:10.1111/ene.14662

PMID:33277744

Abstract

BACKGROUND AND PURPOSE

The CHA DS -VASc score has immense prognostic value in patients with embolic stroke of undetermined source (ESUS). We aimed to determine the usefulness of advanced renal dysfunction and its addition to the CHA DS -VASc score in improving predictive accuracy.

METHODS

In total, 3775 ESUS patients were enrolled from a nationwide hospital-based prospective study. Advanced renal dysfunction was defined as estimated glomerular filtration rate <30 ml/min per 1.73 m or patients under dialysis. Clinical outcomes included recurrent stroke and 1-year all-cause mortality. Poor functional outcome was defined as a modified Rankin Scale >2 at first-, third-, and sixth-month post-stroke. The renal (R)-CHA DS -VASc score was derived by including advanced renal dysfunction in the CHA DS -VASc score. Risk stratification improvement after including advanced renal dysfunction was assessed using C statistic, integrated discrimination improvement (IDI), and category-free net reclassification index (NRI).

RESULTS

After adjusting for confounding factors and CHA DS -VASc score, advanced renal dysfunction showed significant associations with all-cause mortality (HR: 2.88, 95% CI: 1.92-4.34) and poor functional outcome at third- (OR: 2.69, 95% CI: 1.47-4.94) and sixth-month post-stroke (OR: 2.67, 95% CI: 1.47-4.83). IDI and NRI showed that incorporating advanced renal dysfunction significantly improved risk discrimination over the original CHA DS -VASc score. R-CHA DS -VASc score ≥2 increased risk by 1.94-fold (95% CI: 1.15-3.27) for all-cause mortality, and ≥4 increased risk by 1.62-fold (95% CI: 1.05-2.50) of poor functional outcome at third-month post-stroke and by 1.81-fold (95% CI: 1.19-2.75) at sixth-month post-stroke.

CONCLUSIONS

Advanced renal dysfunction was significantly associated with clinical and functional outcomes in ESUS patients and may improve prognostic impact of the CHA DS -VASc score.

摘要

背景与目的

CHA2DS2-VASc 评分在不明来源栓塞性脑卒中（ESUS）患者中具有巨大的预后价值。我们旨在确定肾功能不全的严重程度及其对 CHA2DS2-VASc 评分的补充在提高预测准确性方面的作用。

方法

共纳入了一项全国性基于医院的前瞻性研究中的 3775 例 ESUS 患者。严重肾功能不全定义为估算肾小球滤过率（eGFR）<30 ml/min/1.73 m 或透析患者。临床结局包括复发性卒中和 1 年全因死亡率。功能不良结局定义为卒中后第 1、3 和 6 个月时改良 Rankin 量表评分>2。通过在 CHA2DS2-VASc 评分中纳入严重肾功能不全，衍生出肾（R）-CHA2DS2-VASc 评分。使用 C 统计量、综合判别改善（IDI）和无分类净重新分类指数（NRI）评估纳入严重肾功能不全后风险分层的改善。

结果

在调整混杂因素和 CHA2DS2-VASc 评分后，严重肾功能不全与全因死亡率（HR：2.88，95%置信区间：1.92-4.34）和卒中后第 3 个月（OR：2.69，95%置信区间：1.47-4.94）和第 6 个月（OR：2.67，95%置信区间：1.47-4.83）的不良功能结局显著相关。IDI 和 NRI 表明，纳入严重肾功能不全可显著提高原始 CHA2DS2-VASc 评分的风险判别能力。R-CHA2DS2-VASc 评分≥2 使全因死亡率的风险增加 1.94 倍（95%置信区间：1.15-3.27），评分≥4 使卒中后第 3 个月不良功能结局的风险增加 1.62 倍（95%置信区间：1.05-2.50），使卒中后第 6 个月不良功能结局的风险增加 1.81 倍（95%置信区间：1.19-2.75）。