Department of Nephrology, Gamagori Municipal Hospital, Gamagori, Aichi, Japan.
Department of Nephrology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan.
Nephrology (Carlton). 2024 Aug;29(8):510-518. doi: 10.1111/nep.14311. Epub 2024 May 1.
The Kidney Disease Improving Global Outcomes guidelines recommend nephrology referral for patients with chronic kidney disease (CKD) stages 4 to 5, significant proteinuria and persistent microscopic haematuria. However, the recommendations are opinion-based and which patients with CKD benefit more from nephrology referral has not been elucidated.
In this retrospective cohort study, patients referred to our nephrology outpatient clinic from April 2017 to March 2019 were included. We excluded patients considered to have an acute decline in kidney function (annual decline in estimated glomerular filtration rate [eGFR] >10 mL/min/1.73 m). The slopes of eGFR before and after nephrology referral were estimated and compared by linear mixed effects models. Interaction between time and referral status (before or after referral) was assessed and effect modifications by the presence of diabetes, proteinuria (defined by urine dipstick protein 2+ or more), urine occult blood, hypoalbuminemia (defined by albumin levels less than 3.5 g/dL) and anaemia (defined by haemoglobin levels less than 11.0 g/dL) were evaluated.
The eGFR slope significantly improved from -2.05 (-2.39 to -1.72) to -0.96 (-1.36 to -0.56) mL/min/1.73 m/year after nephrology referral (p < .001). The improvement in eGFR slope was more prominent among those with diabetes mellitus, anaemia, and hypoalbuminemia (all p-values for three-way interaction <.001 after adjustment for covariates). Further adjustments for time-dependent haemoglobin levels, the use of erythropoiesis-stimulating agents, iron supplementation, anti-hypertensives and anti-diabetic medications did not change the significance of the interactions.
Nephrology referral slows CKD progression, especially among those with hypoalbuminemia, diabetes or anaemia. Patients with hypoalbuminemia, diabetes or anaemia might benefit more from specialized care and lifestyle modifications by nephrologists. The inclusion of anaemia and hypoalbuminemia in nephrology referral criteria should be considered.
肾脏病预后质量倡议（Kidney Disease Improving Global Outcomes，KDIGO）指南建议对慢性肾脏病（chronic kidney disease，CKD）4 至 5 期、大量蛋白尿和持续镜下血尿的患者进行肾病学转诊。然而，这些建议是基于意见的，哪些 CKD 患者从肾病学转诊中获益更多尚未阐明。
在这项回顾性队列研究中，纳入了 2017 年 4 月至 2019 年 3 月从我们肾病门诊转诊的患者。我们排除了那些被认为肾功能急性下降（估算肾小球滤过率[eGFR]每年下降>10ml/min/1.73m）的患者。通过线性混合效应模型估计并比较转诊前后 eGFR 的斜率。评估时间与转诊状态（转诊前或转诊后）之间的相互作用，并评估糖尿病、蛋白尿（尿试纸蛋白 2+或以上）、尿潜血、低白蛋白血症（白蛋白水平<3.5g/dL）和贫血（血红蛋白水平<11.0g/dL）存在时的效应修饰。
转诊后 eGFR 斜率从-2.05（-2.39 至-1.72）降至-0.96（-1.36 至-0.56）ml/min/1.73m/年（p<0.001）。在患有糖尿病、贫血和低白蛋白血症的患者中，eGFR 斜率的改善更为明显（所有调整协变量后的三向相互作用 p 值均<.001）。进一步调整时间依赖性血红蛋白水平、使用促红细胞生成素刺激剂、铁补充剂、抗高血压药物和抗糖尿病药物并未改变相互作用的显著性。
肾病学转诊可减缓 CKD 进展，尤其是在低白蛋白血症、糖尿病或贫血的患者中。低白蛋白血症、糖尿病或贫血的患者可能受益于肾病专家的专门护理和生活方式改变。应考虑将贫血和低白蛋白血症纳入肾病学转诊标准。
