Population Health Sciences, School of Life Course and Population Sciences, King's College London, London, UK
Population Health Sciences, School of Life Course and Population Sciences, King's College London, London, UK.
BMJ Open Diabetes Res Care. 2024 Sep 13;12(4):e004282. doi: 10.1136/bmjdrc-2024-004282.
The four variable kidney failure (KF) risk equation (KFRE) is recommended to estimate KF risk (ie, need for dialysis or kidney transplantation). Earlier referral to clinical kidney services for people with high-risk of kidney failure can ensure appropriate care, education and support are in place pre-emptively. There are limited data on investigating the performance of KFRE in estimating risk of end-stage kidney disease (ESKD) in people with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). The primary ESKD endpoint event was defined as estimated glomerular filtration rate (eGFR) <10 mL/min/1.73 m and secondary endpoint eGFR <15 mL/min/1.73 m.
We studied 7296 people (30% women, 41% African-Caribbean, 45% Caucasian) with T2DM and CKD (eGFR median (range) 48 (15-59) mL/min/1.73 m) were included at two hospitals in London (median follow-up 10.2 years). Time to ESKD event was the endpoint and Concordance index (C-index) was used to assess KFRE's discrimination of those experiencing ESKD from those who did not. Mean (integrated calibration index (ICI)) and 90th percentile (E90) of the difference between observed and predicted risks were used as calibration metrics.
Of the cohort 746 (10.2%) reached ESKD primary event (135 (1.9%) and 339 (4.5%) over 2 and 5 years, respectively). Similarly, 1130 (15.5%) reached the secondary endpoint (270 (3.7%) and 547 (7.5%) over 2 and 5 years, respectively). The C-index for the primary endpoint was 0.842 (95% CI 0.836 to 0.848) and 0.816 (95% CI 0.812 to 0.820) for 2 and 5 years, respectively. KFRE 'under-predicted' ESKD risk overall and by ethnic group. Likewise, the C-index for secondary endpoint was 0.843 (0.839-0.847) and 0.801 (0.798-0.804) for 2 and 5 years, respectively. KFRE performance analysis performed more optimally with the primary endpoint with 50% enhancement of the calibration metrics than with the secondary endpoint. KFRE recalibration improved ICI by 50% and E90 by more than 78%.
Although derived for predicting KF, KFRE also demonstrated good discrimination for ESKD outcome. Further studies are needed to identify variables/biomarkers that may improve KFRE's performance/calibration and to aid the development of other predictive models to enable early identification of people at risk of advanced stages of CKD prior to onset of KF.
四变量肾衰竭（KF）风险方程（KFRE）被推荐用于估计肾衰竭风险（即需要透析或肾移植）。对于肾衰竭风险高的人群，更早地转至临床肾脏科服务，可以确保提前提供适当的护理、教育和支持。在患有 2 型糖尿病（T2DM）和慢性肾脏病（CKD）的人群中，KFRE 对估计终末期肾病（ESKD）风险的性能的相关数据有限。主要的 ESKD 终点事件定义为估算肾小球滤过率（eGFR）<10mL/min/1.73m，次要终点为 eGFR<15mL/min/1.73m。
我们研究了在伦敦的两家医院纳入的 7296 名（30%女性，41%非裔加勒比人，45%白种人）患有 T2DM 和 CKD（eGFR 中位数（范围）48（15-59）mL/min/1.73m）的患者。ESKD 事件的时间是终点，一致性指数（C-index）用于评估 KFRE 对经历 ESKD 和未经历 ESKD 的患者的区分能力。观察到的和预测的风险之间的差异的平均值（综合校准指数（ICI））和第 90 个百分位数（E90）被用作校准指标。
该队列中有 746 名（10.2%）达到了 ESKD 主要事件（分别在 2 年和 5 年内达到 135 名（1.9%）和 339 名（4.5%））。同样，有 1130 名（15.5%）达到了次要终点（分别在 2 年和 5 年内达到 270 名（3.7%）和 547 名（7.5%））。主要终点的 C-index 为 0.842（95%CI 0.836-0.848），2 年和 5 年分别为 0.816（95%CI 0.812-0.820）。KFRE 总体上和按族裔群体预测 ESKD 风险的能力不足。同样，次要终点的 C-index 为 0.843（0.839-0.847），2 年和 5 年分别为 0.801（0.798-0.804）。与次要终点相比，KFRE 对主要终点的性能分析表现更优，其校准指标增强了 50%。KFRE 重新校准将 ICI 提高了 50%，E90 提高了 78%以上。
虽然 KFRE 是为预测 KF 而推导的，但它也显示出对 ESKD 结果的良好区分能力。需要进一步研究以确定可能改善 KFRE 性能/校准的变量/生物标志物，并帮助开发其他预测模型，以便在 CKD 进展到晚期肾衰竭之前，早期识别处于高危状态的人群。
