Department of Nephrology, Nagoya City University Graduate School of Medicine, Nagoya, Japan.
Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan.
Nephrol Dial Transplant. 2023 Feb 13;38(2):384-395. doi: 10.1093/ndt/gfac134.
The Kidney Disease: Improving Global Outcomes guidelines advocate the cause-glomerular filtration rate (GFR)-albuminuria (CGA) classification for predicting outcomes. However, there is a dearth of data supporting the use of the cause of chronic kidney disease. This study aimed to address how to incorporate a prior biopsy-proven diagnosis in outcome prediction.
We examined the association of biopsy-proven kidney disease diagnoses with kidney failure with replacement therapy (KFRT) and all-cause death before KFRT in patients with various biopsy-proven diagnoses (n = 778, analysis A) and patients with diabetes mellitus labeled with biopsy-proven diabetic nephropathy (DN), other biopsy-proven diseases and no biopsy (n = 1117, analysis B).
In analysis A, adding biopsy-proven diagnoses to the GFR-albuminuria (GA) classification improved the prediction of 8-year incidence of KFRT and all-cause death significantly regarding integrated discrimination improvement and net reclassification index. Fine-Gray (FG) models with KFRT as a competing event showed significantly higher subdistribution hazard ratios (SHRs) for all-cause death in nephrosclerosis {4.12 [95% confidence interval (CI) 1.11-15.2)], focal segmental glomerulosclerosis [3.77 (95% CI 1.09-13.1)]} and membranous nephropathy (MN) [2.91 (95% CI 1.02-8.30)] than in immunoglobulin A nephropathy (IgAN), while the Cox model failed to show significant associations. Crescentic glomerulonephritis had the highest risk of all-cause death [SHR 5.90 (95% CI 2.05-17.0)]. MN had a significantly lower risk of KFRT than IgAN [SHR 0.45 (95% CI 0.24-0.84)]. In analysis B, other biopsy-proven diseases had a lower risk of KFRT than biopsy-proven DN in the FG model, with death as a competing event [SHR 0.62 (95% CI 0.39-0.97)].
The CGA classification is of greater value in predicting outcomes than the GA classification.
改善全球肾脏病预后组织（KDIGO）指南提倡使用病因-肾小球滤过率（GFR）-白蛋白尿（CGA）分类来预测结局。然而，目前缺乏使用慢性肾脏病病因的数据支持。本研究旨在探讨如何将先前经活检证实的诊断纳入结局预测。
我们研究了各种经活检证实的诊断患者（n=778，分析 A）和患有糖尿病且经活检证实为糖尿病肾病（DN）、其他经活检证实的疾病和未经活检的患者（n=1117，分析 B）中，经活检证实的肾脏疾病诊断与接受肾脏替代治疗的肾衰竭（KFRT）和 KFRT 前全因死亡之间的关联。
在分析 A 中，与 GFR-白蛋白尿（GA）分类相比，将经活检证实的诊断添加到 CGA 分类中，可显著提高 8 年 KFRT 和全因死亡的预测准确性，包括综合判别改善和净重新分类指数。以 KFRT 为竞争事件的 Fine-Gray（FG）模型显示，局灶节段性肾小球硬化症（FSGS）{4.12[95%置信区间（CI）1.11-15.2]}、膜性肾病（MN）{2.91[95%CI 1.02-8.30]}和肾血管性疾病 {4.12[95%置信区间（CI）1.11-15.2]}的全因死亡亚分布风险比（SHR）显著高于免疫球蛋白 A 肾病（IgAN），而 Cox 模型未能显示出显著相关性。新月体肾小球肾炎的全因死亡风险最高[SHR 5.90（95%CI 2.05-17.0）]。与 IgAN 相比，MN 发生 KFRT 的风险显著降低[SHR 0.45（95%CI 0.24-0.84）]。在分析 B 中，FG 模型中，与死亡为竞争事件相比，其他经活检证实的疾病发生 KFRT 的风险低于经活检证实的 DN[SHR 0.62（95%CI 0.39-0.97）]。
与 GA 分类相比，CGA 分类在预测结局方面具有更高的价值。
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