Department of Radiology, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115.
AJR Am J Roentgenol. 2022 Sep;219(3):462-470. doi: 10.2214/AJR.22.27494. Epub 2022 Apr 6.
Practices vary for screening patients for risk of renal dysfunction before administration of iodinated contrast medium. A 2020 American College of Radiology/National Kidney Foundation (ACR/NKF) consensus statement provided streamlined screening criteria. The purpose of this study was to assess the yield of patient-reported risk factors for identifying estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m before outpatient CT. This retrospective study was performed at a health system that implemented an electronic screening form for patients to complete before outpatient CT encounters to report undergoing dialysis, taking cancer-treating medications, having kidney disease, undergoing prior kidney surgery, having diabetes mellitus treated with medication, having hypertension treated with medication, or having multiple myeloma. Patients with any risk factor were required to undergo eGFR testing before CT. Of 44,708 patients completing the form from June 1, 2020, through February 28, 2021, 10,256 patients (5315 men, 4941 women; mean age, 66.8 ± 11.9 [SD] years; range, 21-98 years) underwent eGFR testing on the day of CT. Multivariable regression analysis for predicting reduced eGFR was performed. Findings were compared with those from theoretic use of the ACR/NKF criteria. Same-day testing yielded eGFR less than 30 mL/min/1.73 m in 1.4% (144/10,256) of patients. The only significant independent predictors of low eGFR were dialysis (odds ratio [OR], 203.30], kidney disease (OR, 12.55), and diabetes mellitus treated with medication (OR, 2.44). If the ACR/NKF criteria (only kidney disease, defined as dialysis, kidney disease, or prior kidney surgery) had been followed as a trigger for eGFR testing, the number of patients needing testing would have decreased 89.7%, from 10,256 to 1059; yield would have increased to 7.2% (76/1059); and 47.2% (68/144) of patients with low eGFR would have been missed. If the ACR/NKF criteria had been followed but diabetes mellitus been considered a required rather than an optional criterion, the number of patients needing testing would have decreased 77.1%, to 2353; yield would have increased to 4.0% (95/2353); and 34.0% (49/144) of patients with low eGFR would have been missed. Using patient-reported risk factors resulted in frequent eGFR testing but low yield of low eGFR. Commonly applied risk factors were not independently associated with low eGFR. Application of ACR/NKF criteria would substantially reduce eGFR testing, but patients with renal dysfunction would be missed. The statement should consider omitting kidney surgery as a trigger for eGFR testing and including diabetes mellitus as a required trigger.
在为接受碘造影剂的患者进行肾功能障碍风险筛查之前，实践方法各不相同。2020 年美国放射学院/国家肾脏基金会（ACR/NKF）的一份共识声明提供了简化的筛查标准。本研究的目的是评估患者报告的风险因素在识别门诊 CT 前估计肾小球滤过率（eGFR）<30ml/min/1.73m2 中的作用。这项回顾性研究在一个医疗系统中进行，该系统实施了电子筛查表，让患者在门诊 CT 就诊前完成，以报告接受透析、服用癌症治疗药物、患有肾脏疾病、接受过肾脏手术、患有经药物治疗的糖尿病、患有经药物治疗的高血压或患有多发性骨髓瘤。有任何风险因素的患者都需要在 CT 前进行 eGFR 检测。从 2020 年 6 月 1 日至 2021 年 2 月 28 日，有 44708 名患者完成了表格，其中 10256 名患者（5315 名男性，4941 名女性；平均年龄 66.8±11.9[SD]岁；年龄范围 21-98 岁）在 CT 当天接受了 eGFR 检测。对预测 eGFR 降低的多变量回归分析进行了分析。并将结果与 ACR/NKF 标准的理论应用进行了比较。当天检测出 eGFR<30ml/min/1.73m2 的患者占 1.4%（144/10256）。低 eGFR 的唯一显著独立预测因素是透析（比值比[OR]，203.30）、肾脏疾病（OR，12.55）和经药物治疗的糖尿病（OR，2.44）。如果按照 ACR/NKF 标准（仅肾脏疾病，定义为透析、肾脏疾病或既往肾脏手术）作为 eGFR 检测的触发因素，需要检测的患者数量将减少 89.7%，从 10256 人减少至 1059 人；检出率将增加到 7.2%（76/1059）；并且 47.2%（68/144）的低 eGFR 患者将被漏诊。如果遵循 ACR/NKF 标准，但将糖尿病视为必需而非可选标准，需要检测的患者数量将减少 77.1%，降至 2353 人；检出率将增加到 4.0%（95/2353）；并且 34.0%（49/144）的低 eGFR 患者将被漏诊。使用患者报告的风险因素导致频繁进行 eGFR 检测，但低 eGFR 的检出率较低。常见的应用风险因素与低 eGFR 无独立相关性。应用 ACR/NKF 标准将大大减少 eGFR 检测，但肾功能障碍患者将被漏诊。该声明应考虑将肾脏手术排除在 eGFR 检测的触发因素之外，并将糖尿病视为必需的触发因素。
