心力衰竭合并慢性肾脏病患者的估计肾小球滤过率变异性。
Estimated Glomerular Filtration Rate Variability in Patients With Heart Failure and Chronic Kidney Disease.
机构信息
Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia; Duke Clinical Research Institute, Durham, North Carolina.
出版信息
J Card Fail. 2021 Nov;27(11):1175-1184. doi: 10.1016/j.cardfail.2021.04.016. Epub 2021 May 10.
BACKGROUND
Greater variability in the estimated glomerular filtration rate (eGFR) is associated with higher mortality in patients with chronic kidney disease (CKD). Heart failure (HF) is common in CKD and may increase variability through changes in hemodynamic and volume regulation. We sought to determine if patients with vs without HF have higher kidney function variability in CKD, and to define the association with mortality.
METHODS AND RESULTS
Patients undergoing coronary angiography from 2003 to 2013 with an eGFR of less than 60 mL/min/1.73 m were evaluated from the Duke Databank for Cardiovascular Disease. Variability in the eGFR, measured as the coefficient of variation (CV) of residuals from the regression of eGFR vs time, was calculated spanning 3 months to 2 years after catheterization. Mortality was assessed 2 to 7 years after catheterization. Patients were grouped into 3 HF phenotypes: HF with reduced ejection fraction, HF with preserved ejection, and no HF. Regression was used to evaluate associations between HF phenotypes and variability in the eGFR and between variability in the eGFR and mortality rate with stratification by HF phenotype. Among 3767 participants, the median eGFR at baseline was 45 mL/min/1.73 m (interquartile range 33-53 mL/min/1.73 m), and longitudinal measures of eGFR over 21 months had within-patient residual variability (CV) of 14% (9%-20%). In adjusted analyses, variability in the eGFR was greater in those with HF with preserved ejection (n = 695, CV difference 0.98%, 95% confidence interval 0.14%-1.81%) or HF with reduced ejection fraction (n = 800, CV difference 2.51%, 95% confidence interval 1.66%-3.37%) relative to no HF (n = 2272). In 3068 participants eligible for mortality analysis, the presence of HF and greater variability in the eGFR were each associated independently with higher mortality, but there was no evidence of interaction between variability in the eGFR and any HF phenotype (all P for interaction ≥.49).
CONCLUSIONS
Variability in the eGFR is greater in patients with HF and associated with mortality. Prediction algorithms and classification schemes should consider not only static, but also dynamic eGFR variability in HF and CKD prognostication.
背景
在慢性肾脏病（CKD）患者中，估算肾小球滤过率（eGFR）的变异性越大，死亡率越高。心力衰竭（HF）在 CKD 中很常见，并且可能通过改变血液动力学和容量调节来增加变异性。我们试图确定与 HF 相比，CKD 患者的肾功能变异性是否更高，并定义与死亡率的关系。
方法和结果
从 2003 年至 2013 年接受冠状动脉造影检查的 eGFR 小于 60 mL/min/1.73 m2 的患者，从 Duke 心血管疾病数据库中进行了评估。eGFR 的变异性，通过 eGFR 与时间回归的残差的变异系数（CV）来衡量，计算范围为导管插入后 3 个月至 2 年。导管插入后 2 至 7 年评估死亡率。将患者分为 3 种 HF 表型：射血分数降低型 HF、射血分数保留型 HF 和无 HF。回归用于评估 HF 表型与 eGFR 变异性之间的关系，以及 eGFR 变异性与死亡率之间的关系，并按 HF 表型进行分层。在 3767 名参与者中，基线时 eGFR 的中位数为 45 mL/min/1.73 m2（四分位距为 33-53 mL/min/1.73 m2），21 个月内的 eGFR 纵向测量值的个体内残差变异性（CV）为 14%（9%-20%）。在调整后的分析中，与无 HF 相比，射血分数保留型 HF（n=695，CV 差异 0.98%，95%置信区间 0.14%-1.81%）或射血分数降低型 HF（n=800，CV 差异 2.51%，95%置信区间 1.66%-3.37%）患者的 eGFR 变异性更大。在 3068 名有资格进行死亡率分析的参与者中，HF 的存在和 eGFR 变异性的增加均与死亡率的增加独立相关，但在 eGFR 变异性和任何 HF 表型之间没有证据表明存在交互作用（所有交互作用 P 值均≥.49）。
结论
HF 患者的 eGFR 变异性更大，并且与死亡率相关。预测算法和分类方案不仅应考虑静态，还应考虑 HF 和 CKD 预后中的动态 eGFR 变异性。
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