Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA.
Department of Medicine, George Washington University, Washington, DC, USA.
Eur J Heart Fail. 2024 May;26(5):1251-1260. doi: 10.1002/ejhf.3210. Epub 2024 May 3.
According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes.
Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m (n = 185 821) or urinary albumin-to-creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m, present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m were categorized into four stages: 45-59 (n = 72 606), 30-44 (n = 74 812), 15-29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m. Five-year all-cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all-cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62-1.65), 2.00 (1.98-2.02), 2.49 (2.45-2.52), 2.28 (2.21-2.35), and 1.22 (1.20-1.24), respectively. Respective age-adjusted HRs (95% CIs) were 1.13 (1.12-1.14), 1.36 (1.34-1.37), 1.87 (1.84-1.89), 2.24 (2.18-2.31) and 1.19 (1.17-1.21), and multivariable-adjusted HRs (95% CIs) were 1.11 (1.10-1.12), 1.24 (1.22-1.25), 1.46 (1.43-1.48), 1.42 (1.38-1.47), and 1.13 (1.11-1.16). Similar patterns were observed for associations with hospitalizations.
Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO-defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria.
根据肾脏病：改善全球预后（KDIGO）指南，慢性肾脏病（CKD）的定义需要存在异常的肾脏结构或功能>3 个月，这对健康有影响。心力衰竭（HF）患者的 CKD 尚未按照该定义进行定义，对于这些患者中 CKD 的真正健康影响知之甚少。本研究的目的是确定符合 KDIGO CKD 标准的 HF 患者，并检查其结局。
在 1419729 名未接受肾脏替代治疗的 HF 退伍军人中，有 828744 名患者有≥2 次相隔>90 天的门诊血清肌酐数据。CKD 的定义为估算肾小球滤过率（eGFR）<60ml/min/1.73m（n=185821）或尿白蛋白/肌酐比（uACR）>30mg/g（n=32730）两次相隔>3 个月。正常肾功能（NKF）的定义为 eGFR≥60ml/min/1.73m，持续>3 个月，且无任何 uACR>30mg/g（n=365963）。eGFR<60ml/min/1.73m 的患者分为四个阶段：45-59（n=72606）、30-44（n=74812）、15-29（n=32077）和<15（n=6326）ml/min/1.73m。在五年内，分别有 40.4%、57.8%、65.6%、73.3%、69.7%和 47.5%的 NKF、四个 eGFR 阶段和 uACR>30mg/g（白蛋白尿）患者发生全因死亡。与 NKF 相比，与四个 eGFR 阶段和白蛋白尿相关的全因死亡率的危险比（HR）（95%置信区间[CI]）分别为 1.63（1.62-1.65）、2.00（1.98-2.02）、2.49（2.45-2.52）、2.28（2.21-2.35）和 1.22（1.20-1.24）。相应的年龄调整 HR（95%CI）分别为 1.13（1.12-1.14）、1.36（1.34-1.37）、1.87（1.84-1.89）、2.24（2.18-2.31）和 1.19（1.17-1.21），多变量调整 HR（95%CI）分别为 1.11（1.10-1.12）、1.24（1.22-1.25）、1.46（1.43-1.48）、1.42（1.38-1.47）和 1.13（1.11-1.16）。与住院相关的关联也呈现出类似的模式。
有六分之一的患者可以获得使用 KDIGO 标准定义 CKD 的所需数据，有十分之七的患者可以用数据来定义 CKD。符合 KDIGO 定义的 CKD 的 HF 患者发生不良结局的风险更高，其中大部分风险不能用异常的肾脏结构或功能来解释。未来的研究需要检查使用单一 eGFR 定义的 CKD 是否与使用 KDIGO 标准定义的 CKD 在特征和预后上有明显不同。
