IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT, Madrid, Spain.
ISCIII RICORS2040 Kidney Disease Research Network, Madrid, Spain.
Nephrol Dial Transplant. 2023 Dec 20;39(1):151-158. doi: 10.1093/ndt/gfad154.
Chronic kidney disease (CKD) is diagnosed when glomerular filtration rate (GFR) falls below 60 ml/min/1.73 m2 or urinary albumin:creatinine ratio (UACR) reaches ≥30 mg/g, as these two thresholds indicate a higher risk of adverse health outcomes, including cardiovascular mortality. CKD is classified as mild, moderate or severe, based on GFR and UACR values, and the latter two classifications convey a high or very high cardiovascular risk, respectively. Additionally, CKD can be diagnosed based on abnormalities detected by histology or imaging. Lupus nephritis (LN) is a cause of CKD. Despite the high cardiovascular mortality of patients with LN, neither albuminuria nor CKD are discussed in the 2019 European League Against Rheumatism (EULAR)/European Renal Association-European Dialysis and Transplant Association recommendations for the management of LN or the more recent 2022 EULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases. Indeed, the proteinuria target values discussed in the recommendations may be present in patients with severe CKD and a very high cardiovascular risk who may benefit from guidance detailed in the 2021 European Society of Cardiology guidelines on cardiovascular disease prevention in clinical practice. We propose that the recommendations should move from a conceptual framework of LN as an entity separate from CKD to a framework in which LN is considered a cause of CKD and evidence generated from large CKD trials applies unless demonstrated otherwise.
慢性肾脏病（CKD）的诊断标准为肾小球滤过率（GFR）降至 60ml/min/1.73m2 以下或尿白蛋白与肌酐比值（UACR）达到≥30mg/g，因为这两个阈值提示发生不良健康结局（包括心血管死亡）的风险较高。根据 GFR 和 UACR 值，CKD 可分为轻度、中度或重度，后两种分类分别表示存在较高和极高的心血管风险。此外，CKD 也可基于组织学或影像学检查发现的异常来诊断。狼疮肾炎（LN）是 CKD 的病因之一。尽管 LN 患者的心血管死亡率较高，但在 2019 年欧洲抗风湿病联盟（EULAR）/欧洲肾脏协会-欧洲透析和移植协会（ERA-EDTA）关于 LN 管理的建议或最近 2022 年 EULAR 关于风湿和肌肉骨骼疾病心血管风险管理的建议中，既没有讨论蛋白尿，也没有讨论 CKD。实际上，在这些建议中讨论的蛋白尿靶值可能存在于伴有严重 CKD 和极高心血管风险的患者中，这些患者可能受益于 2021 年欧洲心脏病学会（ESC）关于临床实践中心血管疾病预防指南中详细的指导。我们建议，这些建议应从将 LN 作为与 CKD 不同实体的概念框架转变为将 LN 视为 CKD 病因的框架，除非有证据表明并非如此，否则应采用来自大型 CKD 试验的证据。
