关于老年慢性肾脏病诊断标准的争议

目前的慢性肾脏病(CKD)诊断标准在很多地方忽视了老年人的特殊性.在评估肾功能方面,由于血清肌酐水平受到肌肉含量、饮食等许多因素的影响,因此,所有基于血清肌酐的肾小球滤过率( GFR)评估公式在实际应用特别是在老年人群中应用时均会出现一定的偏倚.近年来,很多研究证实血清胱抑素C是一项干扰因素较少、相对理想的测定GFR的...     

老年慢性肾脏病3期患者肾脏功能储备的评价

目的评价老年慢性肾脏病(CKD)3期患者的肾脏功能储备(RFR)水平。方法 选取2020年1月至2020年12月于北京友谊医院老年医学科住院的123例患者为研究对象。采用基于血清胱抑素C联合血清肌酐的公式计算估算肾小球滤过率(eGFR)。根据eGFR水平将患者分为CKD3a期组(n=75)和CKD3b期组(n=48)。以静脉输注氨基酸刺激前后eGFR的差值计算RFR。比较2组患者的一般临床资料及RFR水平差异。观察临床随访1年时,不同RFR水平患者发生急性肾损伤(AKI)及肾功能快速下降的差异。采用SPSS 21.0统计软件进行数据分析。根据数据类型,组间比较分别采用两独立样本t检验、单因素方差分析或χ²检验。结果 65～75岁患者RFR水平为(21.61±7.13)ml/(min·1.73m²),76～85岁患者RFR水平为(12.80±9.33)ml/(min·1.73m²),>85岁患者RFR水平为(7.23±5.84)ml/(min·1.73m²),多组间两两比较差异均有统计学意义(P...     

Association between waist-to-hip ratio and chronic kidney disease in the elderly

Background:  To compare the anthropometric indices of obesity and identify which index serves as a better discriminator in the chronic kidney disease (CKD) for the elderly.
Methods:  Participants of a 1-day health check, older than 60 years, in our hospital from 2003 to 2005 were enrolled. CKD was defined as estimated glomerular filtration rate by modification of diet in renal disease formula less than 60 mL/min per 1.73 m². Indices of obesity include body mass index, waist circumference, waist-to-hip ratio (WHR) and waist-to-height ratio. Traditional risk factors including diabetes, hypertension and metabolic syndrome were also taken into consideration. The accuracy of indices of obesity in predicting CKD was measured by area under the receiver operating characteristic curve (AUC). Association between risk factors was estimated by multivariate logistic regression.
Results:  We studied 984 participants (537 men and 447 women) with a mean age of 66.7 ± 5.3 years. A total of 161 (16.4%) participants was found having CKD. In the indices of obesity, WHR showed best diagnostic accuracy in predicting CKD (AUC: 0.58). A WHR cut-off value of 0.88 had a sensitivity of 68.9% and a specificity of 45.4%. The odds ratios were significant for WHR, hypertension and diabetes ( P  = 0.025, P  < 0.001 and P  = 0.033).
Conclusion:  In indices of obesity, WHR is better than body mass index, bodyweight and waist circumferences in predicting CKD in elder Taiwanese. Furthermore, the association of WHR and CKD is independent of hypertension and diabetes.     

Hip fractures in elderly patients with non-dialysis dependent chronic kidney disease: Outcomes in a Southeast Asian population

Chronic kidney disease (CKD) causes bone and mineral disorders and alterations in vitamin D metabolism that contribute to greater skeletal fragility. Hip fracture in elderly is associated with significant morbidity and mortality. The aim of this study was to investigate the outcome of elderly patients with non-dialysis dependent CKD and hip fracture undergoing surgery.Retrospective study with IRB approval of patients above 65 years of age, with hip fractures admitted between June 2014 to June 2016 in a Southeast Asian cohort. Data collected included demographic variables and the haematological and biochemical parameters HBA1c, estimated glomerular filtration rate (eGFR), serum calcium, phosphorous, and 25(OH) Vitamin D. Co-morbidities investigated were ischemic heart disease, congestive heart failure, peripheral vascular disease, malignancy, chronic obstructive pulmonary disease, cerebro vascular accident, hypertension and hyperlipidaemia. All patients were followed up from index date to either death or June 1, 2018.Of the 883 patients, 725 underwent surgery and 334 had CKD. Death rates for CKD patients with hip fractures and those with normal renal function did not differ significantly [8.08% vs 6.54%, (HR= 1.33, 95% CI: 0.95, 1.86; P = .102)], whilst median hospital length of stay was significantly higher in CKD patients [10.5 vs 9.03 days (P = .003)]. Significant risk factors associated with higher risk of mortality in the elderly with hip fracture were male gender, age ≥80 years and serum albumin < 30 g/L (all, P < .0001).In summary, in elderly, non-dialysis dependent CKD patient with hip fracture we found that male gender, age ≥80 years, low serum albumin and eGFR < 30 mL/min/1.73 m² were associated with higher risk of death. The hospital stay in the CKD group was also longer. Additional studies are needed to validate our findings.     

老年慢性肾脏病合并肌少症的研究进展

肌少症是以骨骼肌质量、力量及功能降低为主要特征的退行性综合征。肌少症与衰老密切相关,但是,慢性肾脏病等疾病可以加速肌肉消耗,增加肌少症的发生率。慢性肾脏病患者易合并肌少症,其机制涉及炎症反应、蛋白质能量消耗、运动减少及维生素D缺乏等。早期识别肌少症的危险因素并对其进行干预,对于慢性肾脏病合并肌少症患者生活质量的改善至关重要。目前,干预措施主要有体育锻炼、营养补充及药物治疗等。本文就近年对老年慢性肾脏病合并肌少症的发病情况、机制及治疗的研究进展作一综述。     

Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension

Blood pressure (BP) usually rise from being asleep to awake, which is named the morning blood pressure surge (MBPS). Researches have reported that elevated MBPS was related with CV events, incident CKD in hypertensive patients. However, there have been no studies that have investigated the association between MBPS and renal or heart outcomes in patients with CKD and hypertension, in these patients, the MBPS is much lower because of high prevalence of night hypertension and reduced BP dipping. In this prospective two‐center observational study, we enrolled patients with CKD and hypertension and the 24 h ambulatory blood pressure monitoring (ABPM) was conducted in all patients. Time to total mortality, CKD progression and CV events was recorded; Finally, a total of 304 patients were enrolled and 94 (30.9%) of them had elevated MBPS. After a follow‐up for median 30 months, 23 (7.6%), 34 (11.2%), and 95 (31.3%) patients occurred death, CKD progression and new‐onset CV events, respectively. The Cox regression analysis suggested the elevated MBPS was a strong predictor of CKD progression (HR 2.35, 95%CI 1.2 ‐4.63, p = .013), independent of morning BP, while no associations were found between elevated MBPS and CV events (HR 1.02, 95%CI 0.66 ‐1.57), as well as death (HR 1.08, 95%CI 0.46 ‐2.55). In conclusion, we provided the first evidence that elevated MBPS was an important risk factor of CKD progression in patients with CKD and hypertension. Appropriate evaluation and management of MBPS may be helpful to postpone CKD progression.     

White‐coat and masked hypertension diagnoses in chronic kidney disease patients

The purpose of this study was to analyze which 24‐hour ambulatory blood pressure measurement (ABPM) parameters should be used on masked hypertension (MH) and white‐coat hypertension (WCH) diagnoses in chronic kidney disease (CKD) patients. Non‐dialysis CKD patients underwent 24‐hour ABPM examination between 01/27/2004 and 02/16/2012. They were followed from the 24‐hour ABPM to January/2014 in an observational study. The WCH definitions tested were as follows: (a) office blood pressure (BP) ≥ 140/90 mm Hg and daytime ABPM BP ≤ 135/85 mm Hg (old criterion); and (b) office BP ≥ 140/90 mm Hg and 24‐hour ABPM BP ≤ 130/80 mm Hg, daytime ABPM BP ≤ 135/85 mm Hg, and nighttime ABPM BP ≤ 120/70 mm Hg (new criterion). The MH definitions tested were as follows: (a) office BP < 140/90 mm Hg and daytime ABPM BP > 135/85 mm Hg (old criterion); and (b) office BP < 140/90 mm Hg and 24‐hour ABPM BP > 130/80 mm Hg or daytime ABPM BP > 135/85 mm Hg or nighttime ABPM BP > 120/70 mm Hg (new criterion). The two definitions' predictive capacity was compared, regarding both WCH and MH. Cardiovascular mortality was the primary and all‐cause mortality was the secondary outcome. Cox regression was adjusted to the variables: glomerular filtration rate, age, diabetes mellitus, and active smoking. There were 367 patients studied. The old criterion (exclusive mean daytime ABPM BP) was the only to distinguish sustained hypertension from WCH (adjusted HR: 3.730; 95% CI: 1.068‐13.029; P = .039), regarding all‐cause mortality. Additionally, the old criterion was the only one to distinguish normotension and MH, regarding cardiovascular mortality (adjusted HR: 7.641; 95% CI: 1.277‐45.738; P = .026). Therefore, WCH and MH definitions based exclusively on daytime ABPM BP values (old criterion) were able to better distinguish mortality in this studied CKD cohort.     

Timing of Initiation of RRT and Modality Selection

There is no shortage of studies and registry data examining outcomes of patients on dialysis and those with a renal transplant. However, recently, there has been a greater focus on the events leading up to the institution of kidney replacement therapy. Associative data suggest that early and consistent predialysis care leads to better outcomes, including greater take-on to home-based therapy, diminished use of tunneled venous hemodialysis catheters, and improved early and even late survival. What transpires during predialysis visits is also important. Simple dissemination of facts to the unprepared patient is unlikely to be effective in moving the patient and family along in the process of the series of choices that have to be made around therapy. A more flexible and circumspect approach is needed, including recognizing when the patient is or is not ready for change. There seems to be no optimal timing of dialysis start that can be applied to the ESRD population as a whole, although the pendulum seems to be swinging back toward symptom-based rather than eGFR-based starts.     

夜间高血压监测对慢性肾脏病的临床意义

慢性肾脏病(CKD,chronic kidney disease)是全球性的健康问题,且发病率日益增长,中国CKD3~5期患病率已达10.5%~11.8%[1-2]。高血压既是引起CKD的病因,也是CKD导致的主要并发症之一。肾功能正常或近正常的CKD患者高血压患病率65%,而终末期肾病(end stage renal disease,ESRD)高血压患病率升高至95%[3]。2012年,高血压已成为美国ESRD的第二大主要原因(34%),仅次于糖尿病。肾小球滤过率的降低与高血压患病率和血压控制达标比例有关[4]。     

血压评估参数与老年男性慢性肾脏病合并高血压病人肾功能下降的关系

目的 研究不同血压评估参数与老年男性慢性肾脏病(CKD)3～4期合并高血压病人肾功能下降的关系.方法 对2015年1月至2019年12月北京同仁医院老年医学科/干部医疗科112例CKD 3～4期合并高血压的老年男性病人的临床资料进行回顾性分析,记录病人连续2年临床检验数据及此2年间动态血压监测数据.以2年间eGFR减低...     

Utilization of antihypertensive drugs among chronic kidney disease patients: Results from the Chinese cohort study of chronic kidney disease (C‐STRIDE)

The utilization of antihypertensive drugs plays an important role in blood pressure control among chronic kidney disease (CKD) patients. Limited information was available on how antihypertensive drugs were used among Chinese CKD patients. In the present study, the utilization of antihypertensive drugs among a subgroup of hypertensive participants with a complete record of antihypertensive drug information from the Chinese Cohort Study of Chronic Kidney Disease was analyzed. Among 2213 subjects, 61.7% and 26.5% had their blood pressure controlled to <140/90 mmHg and <130/80 mmHg, respectively. In total, 38.5% were on monotherapy. Of those patients who received combination therapy, 57.8% were treated with a two‐drug combination. Renin‐angiotensin system inhibitors (RASIs) were the most commonly prescribed drugs (71.2%). Only 10.2% of the patients were prescribed diuretics. After multivariable adjustment, participants taking RASI were more likely to have their blood pressure controlled to <140/90 mmHg (prevalence ratio (PR) 1.153, 95% confidence interval (CI): 1.071‐1.240). CKD stage 4 (PR 0.548, 95% CI: 0.434‐0.692) was associated with RASIs treatment. Additionally, diabetes (PR 1.498, 95% CI: 1.120‐2.004), albumin/creatinine ratio ≥300 mg/g (PR 1.547, 95% CI: 1.020‐2.344), and CKD stage 4 (PR 2.022, 95% CI: 1.223‐3.343) were associated with diuretic use. The results suggested that combination therapy, diuretics use in general, and utilization of RASIs in advanced CKD stage were insufficient in the current treatment of Chinese hypertensive CKD patients.     

高血压与肾脏病

高血压是全世界主要的公众健康问题之一,是心力衰竭及终末期肾病的独立危险因素.慢性肾脏病同样是全球性的健康问题,具有较高的发病率和病死率,因此给社会带来了沉重的经济负担.大量研究表明,高血压是导致肾脏病的原因,也是肾脏病的结果.微量白蛋白尿是高血压肾损害的早期指标,严格的血压控制可减少蛋白尿,延缓肾脏病的进展.本文对这两种疾病的发病率、危险因素、相互关系、治疗等方面进行了综述.     

Urinary vanin‐1 associated with chronic kidney disease in hypertensive patients: A pilot study

Hypertension and chronic kidney disease (CKD) are serious interrelated public health problems. Despite the monitoring and control of high blood pressure, symptoms of CKD are not usually apparent in its early stages. Previously, we reported the utility of urinary vanin‐1 as an early biomarker of kidney injury in spontaneously hypertensive rats, but it remains unknown whether urinary vanin‐1 is associated with CKD in humans. In this study, we estimated associations between urinary vanin‐1 and parameters of kidney function in a cross‐sectional study of hypertensive patients. We measured concentrations of vanin‐1 using spot urine from 147 adult hypertensive patients (mean age, 72.8 years; 39.5% women). Patients were divided into 2 groups based on the median of the estimated glomerular filtration rate (eGFR). The group with eGFR < 60 mL/min per 1.73 m² showed significantly higher levels of urinary vanin‐1 than those with eGFR ≥ 60 mL/min per 1.73 m². On univariate analysis, urinary vanin‐1 as well as neutrophil gelatinase‐associated lipocalin (NGAL) showed significant negative correlations with eGFR; however, multivariate analysis revealed that urinary vanin‐1, but not NGAL, significantly correlated with eGFR. In addition, urinary vanin‐1 had a significant positive correlation with the urinary protein‐to‐creatinine ratio (UPCR) (r = 0.21; P = .021) and albumin‐to‐creatinine ratio (UACR) (r = 0.61; P < .01). In conclusion, urinary vanin‐1 is associated with lower eGFR and higher UPCR and UACR, and might be a potential marker of decreased kidney function in hypertensive patients. Further studies are needed to confirm these findings.     

原发性高血压合并慢性肾脏病的危险因素分析

目的:探讨原发性高血压(EH)住院患者中慢性肾脏病(CKD)患病率及危险因素的分析. 方法:回顾性分析2011年2月至2012年2月新疆医科大学第一附属医院高血压科住院确诊的EH患者982例,探讨EH合并CKD的发生情况,对其危险因素分别进行单因素及多因素Logistic回归分析. 结果:(1)EH患者合并蛋白尿、估算的肾小球滤过率(eGFR)下降、CKD的患者构成比分别为20.3％、5.2％、23.5％,男性和女性EH中CKD构成比为26.6％vs20.2％(P＞0.05);汉族和维族EH合并CKD的构成比为22.7％ vs 26.0％ (P＞0.05).(2)收缩压每升高20 mmHg,CKD的构成比明显增加,差异有统计学意义.(3)多因素Logistic回归分析表明,收缩压≥140mmHg(OR=1.503,95％ CI 1.021 ～2.212)、糖尿病病史(OR=1.661,95％ CI 1.174 ～2.351)、高尿酸血症(OR=1.691,95％CI 1.194 ～2.395)是EH合并CKD的独立危险因素. 结论:控制血尿酸、血糖和血压水平可减少EH合并CKD的发生和发展.     

尿微量白蛋白/肌酐在老年健康体检人群慢性肾脏病筛查中的应用

目的 探讨尿微量白蛋白/肌酐(ACR)在老年健康体检人群慢性肾脏病(CKD)筛查中的应用.方法 随机选择2016年3月至2019年6月在南京医科大学第二附属医院健康管理中心行ACR检查的1029名老年健康体检人员,以ACR检测结果分为2组:ACR≥30 mg/g为ACR+组,ACR<30 mg/g为ACR-组,比较2组...     

慢性肾脏病合并心肾综合征的处理策略

慢性肾脏病(CKD)合并心肾综合征(CRS)在老年患者中较为常见,临床表现比较复杂。CKD合并CRS的临床处理原则是根据心、肾功能损伤的原因和临床表现对CRS进行分型,准确判断病情恶化的主要症结,依据不同的情况分别进行处理。纠正贫血、减轻水钠潴留以及改善利尿剂抵抗是此类患者治疗中的共性问题。ACEI、β受体阻滞剂和强心苷类药物在这些患者中应用安全有效,但需要小心用药、严密监测。CRS干预治疗的长期效果尚需更多的前瞻性临床研究。     

Hypertension and chronic kidney disease in Asian populations

The countries of Asia are home to multiple ethnicities. There are ethnic differences in diet, culture, and attitudes towards health screening, access to care, and treatment of chronic diseases. Chronic kidney disease (CKD) and end‐stage kidney disease (ESKD) have rising incidence and prevalence due to increased affliction with non‐communicable diseases of diabetes and hypertension. To prevent the expensive complications of ESKD, one of the most important risk factors to control is hypertension in patients with CKD. We performed a narrative review on the prevalence of CKD in patients with hypertension, the prevalence and control of hypertension in patients with CKD, and the dietary sodium intake in CKD populations.