肾小球滤过率对造影剂肾病的早期预测价值

目的 探讨肾小球滤过率（eGFR）对行冠状动脉介入诊断和治疗患者发生造影剂肾病（CIN）的早期预测价值.方法 收集我院心内科行冠脉介入诊治术[冠状动脉造影术（CA）和（或）经皮冠状动脉介入术（PCI）]患者184例,检测患者术前（组1）、术后24 h（组2）及术后72 h（组3）血清肌酐（Scr）、尿素氮（BUN）水平,并应用MDRD公式计算三组患者的eGFR值,分析比较Scr与eGFR变化对患者肾功能受损的预测价值.结果 ①三组间BUN差异无统计学意义,Scr于术后72 h明显升高,而eGFR于术后24 h即显著下降.②以术后患者Scr较基础值升高25%诊断CIN（方法A）,组2、组3分别为28例（15.2%）、68例（37.0%）;而以eGFR＜60 ml·min-1·1.73m-2诊断CIN（方法B）,组1、组2、组3分别为44例（23.9%）、60例（32.6%）、72例（39.1%）,两种方法比较,术后24 h eGFR值降低先于Scr水平,差异具有统计学意义（P＜0.01）.③术前以eGFR＜90 ml·min-1·1.73m-2为界诊为肾功能受损者44例（31.4%）,而Scr水平虽有增高但仍在正常范围内;术前肾功能受损组CIN发病率明显高于肾功能正常组.结论 eGFR下降总是先于Scr水平变化,是早期肾功能损害及损害程度的强预测因子.介入术前计算eGFR可有效评估患者肾功能状况,术后可及早发现CIN,采取相应干预措施,有助于减少急性肾功能衰竭的发生.     

肾小球滤过率是除蛋白尿外评估2型糖尿病肾病的重要因素

背景与目的：血脂异常促进糖尿病微血管病的进展，但是在糖尿病肾病（DN）各期中发挥重要作用的血脂成分并不相同。本文旨在研究血脂异常类型与1型糖尿病肾病进展的关系。     

重视糖尿病慢性肾疾病的早期筛查

随着糖尿病发病率在全球范围内逐年增加，糖尿病患者生存时间的逐渐延长，糖尿病导致慢性肾脏疾病（CKD）的患病比例也在逐年增加。目前糖尿病已成为西方国家终末期肾病（ESRD）以及进行肾替代治疗的最主要病因。     

临床常用肾小球滤过率评估方程在2型糖尿病患者中的效能比较

目的评价目前临床常用的肾小球滤过率（GFR）评估方程在2型糖尿病患者中的准确性和适用性。方法入选2007年10月至2010年12月在广州中山大学附属第三医院肾内科及内分泌科住院的2型糖尿病患者224例,其中男133例,女91例,平均年龄（60±13）岁。测定血清肌酐和胱抑素C水平,以体表面积标化的锝-二乙三胺五乙酸（^99mTcDTPA）测得的GFR（sGFR）为标准,采用肾脏病膳食改良试验方程（MDRD）、中国方程、Cockcroft—Gault方程、慢性肾脏病流行病合作组方程（EPI方程）、瑞金方程、慢性肾脏病流行病合作组胱抑素方程（EPI—Cysl方程及EPI-Cys2方程）以及MacIsaac胱抑素方程估测GFR值。应用Bland—Altman分析、线性相关分析及受试者工作特征曲线进行数据统计。结果（1）Bland—Altman分析显示,EPI—Cysl方程、EPI—Cys2方程及MacIsaac胱抑素方程估测的GFR与sGFR的一致性最好,所有方程估测的GFR与sGFR的一致性限度均超过预定的界值;EPI．Cysl方程、EPI—Cys2方程及MacIsaac胱抑素方程与x轴的斜率分别为0．168、0．183、0．186;MacIsaac胱抑素方程与Y轴的截距最小。（2）胱抑素C推导的3个方程偏差较小,30％符合率达60％以上,50％符合率达85％;EPI．Cysl方程和EPI-Cys2方程低估GFR,血肌酐推导的5个方程高估GFR。（3）诊断慢性肾病的效能方面,EPI—Cysl方程及EPI-Cys2方程的准确性和敏感度较高（分别为88％和94％）,MacIsaac胱抑素方程和瑞金方程的截点值分别为62．4、64．9ml·min-1·1．73m-1,与原分割点（60ml·min-1·1．73m-2）吻合度较高。结论8个GFR方程估算的GFR均存在不同程度的误差,胱抑素C推导方程总体效能高于血肌酐推导方程,瑞金方程在血肌酐推导方程中效能较高。在今后广泛用于临床前,所有方程仍需进一步进行校正。     

2型糖尿病患者肾小球滤过率年下降率测定及其相关因素分析

目的探讨2型糖尿病（T2DM）患者肾小球滤过率（GFR）年下降率及其影响因素。方法1994-2008年进行两次核素测定GFR的T2DM住院患者309例,根据基线尿白蛋白排泄率（UAER）和血肌酐（Scr）分为3组：正常白蛋白尿（N-UAlb）组、微量白蛋白尿（M-UAlb）组、大量蛋白尿（L-UAlb）组;根据末次测定GFR时的UAER和Scr各组再分为无进展组与有进展组,计算GFR年下降率。结果3组GFR末次值与基线值比较,有进展组与无进展组差异均有统计学意义（P〈O．01）。GFR年下降率：N_UAlb无进展组为1．5±7．3ml／min,有进展组为3．2±3．9ml／minM．UAlb无进展组为2．7±9．2ml／min,有进展组为4．1±8．5ml／min;L-UAlb组为9．4±11．9ml／minN—UAlb组、M—UAlb组与L_UAlb组比较,GFR年下降率有进展组与无进展组差异均有统计学意义（P〈O．01）。HbA。C、收缩压与GFR年下降率呈独立正相关（r=0.92、0．06,P〈0．05）。结论T2DM患者GFR年下降率随UAlb的严重程度而逐渐增加,HbA1c、收缩压是GFR年下降率的独立危险因素。     

糖尿病前期患者肾小球滤过率影响因素的相关分析

目的 探讨影响糖尿病前期患者肾小球滤过率(GFR)的危险因素.方法 自2007年1月至2009年7月,对南通大学第二附属医院内分泌科门诊通过75g口服葡萄糖耐量试验筛查出的糖尿病前期患者165例,按1999年世界卫生组织诊断标准,分为空腹血糖受损组(IFG组,42例)、糖耐量减低组(IGT组,56例)、IFG合并IGT组(CGI组,64例),并选取同期体检正常的人群作为对照组(NGT组,30例).检测各组空腹血糖、胰岛素、糖负荷后2h血糖(Gluc120),GFR等,计算稳态时各组胰岛素抵抗指数(HOMA-IR)、胰岛细胞分泌功能指数(HOMA-B%)和糖负荷状态下早相胰岛素分泌指数(ΔI30/ΔG30)、第二时相胰岛素分泌指数(AUC120).统计学采用Pearson线性相关分析及多元线性逐步回归分析.结果 (1)GFR在NGT、IFG、IGT、CGI组依次升高,组间比较差异具有统计学意义[各组GFR分别为(103±12、113±13、133±16、143±14)ml/min,P<0.05];(2)线性相关分析示GFR与体重指数、HOMA-IR、空腹胰岛素、Gluc120、AUC120呈正相关(r值分别为0.571、0.842、0.606、0.788、0.528,均P<0.01),GFR与ΔI30/ΔG30呈负相关(r=-0.628,P<0.01);(3)逐步回归分析示GFR的影响因素是HOMA-IR、Gluc120、ΔI30/ΔG30、AUC120(β值分别为0.631、0.343、-0.198、0.248,均P<0.05).结论 初步考虑糖尿病前期患者GFR增高的危险因素是HOMA-IR、Gluc120、AUC120升高和ΔI30/ΔG30降低,早期干预糖尿病肾病的发生发展需要控制血糖、减轻胰岛素抵抗和改善胰岛细胞功能.     

糖尿病患者肾小球滤过率评估方法的评价

目前糖尿病肾脏疾病的筛查以尿白蛋白排泄率为主要参考指标,但糖尿病肾病作为慢性肾脏疾病（CKD）的一种,肾小球滤过率（GFR）的评估也及其重要。美国糖尿病协会（ADA）指出单独的血肌酐检查不能作为评估肾功能的指标,所有成年糖尿病患者,不论其尿白蛋白排泄情况如何,每年均应至少检查1次血肌酐以评估GFR。     

老年2型糖尿病肾病患者残余尿量与肾小球滤过率的相关性

目的评估无排尿症状的老年2型糖尿病(T2DM)肾病(DN)患者残余尿量(PVR)与肾小球滤过率(e GFR)的相关性。方法调查收治的门诊随访无排尿症状的T2DM患者42例,年龄53~85岁,平均(58.2±3.6)岁,其中男19例,女23例,国际前列腺症状评分(IPSS)评分0~11分,平均3.7分,病程1~34年,平均11.9年。对患者的泌尿系统、视网膜病变、神经病变及程度进行评估,采用膀胱扫描仪测量PVR,检查尿微量白蛋白含量及e GFR进行相关性分析。结果神经病变患者与视网膜病变患者较非神经病变或视网膜病变患者的PVR高,但无统计学意义(P0.05)。而DN患者的PVR较非DN患者高(P=0.04)。7例(16.7%)患者的PVR50 ml,平均e GFR显著降低,其中1例(14.3%)为微量白蛋白尿,6例(85.7%)伴有明显蛋白尿。e GFR和PVR具有显著负相关性(r=-0.33,P=0.03),e GFR升高则是PVR50 ml的一个重要危险因素(OR=:0.94;95%CI:0.88~0.99;P=0.04)。结论 e GFR下降是PVR50 ml的一个独立的危险因素,可通过早期测量PVR预测DN的发生,降低e GFR早期预防及治疗DN并发症。     

肾动态显像法与双血浆法在糖尿病肾病患者肾小球滤过率测定中的价值比较

目的比较肾动态显像法与双血浆法在糖尿病肾病(DN)患者肾小球滤过率(GFR)测定中的价值。方法将该院内分泌科患者68例DN患者分为早期肾病组(DN1)23例、临床肾病组(DN2)23例、尿毒症组(DN3)22例,另选取该院22例健康体检者作为健康对照组(DN0),均用肾动态显像法和双血浆法测定其GFR,分析各组两种方法所测GFR的关系。结果 DN0、DN1及DN2组组内用肾动态显像法和双血浆法测定的GFR(即g GFR与t GFR)相比均无明显差异(P0.05),DN3组g GFR与t GFR的差异具有统计学意义(P0.05);DN0、DN1、DN2及DN3组肾动态显像法所测的GFR与双血浆法测定的GFR均呈正相关(P0.05)。结论肾动态显像法与双血浆法均可以灵敏地发现早期DN及临床DN时GFR的变化,但肾动态显像法对于尿毒症期的患者诊断准确性差、灵敏度低,应联合病史及其他检查方法进行诊断。     

A strong correlation between glomerular filtration rate and filtration surface in diabetic nephropathy

Summary Quantitative structural studies were performed in kidney biopsy specimens from 24 long-term Type 1 (insulin-dependent) diabetic patients with persistent albuminuria due to diabetic glomerulopathy. Ten patients were receiving antihypertensive treatment, and among the remaining patients the mean blood pressure was 142/91 mmHg (SD = 11/9). The urinary albumin excretion rate showed a range from 100 to 5494 g/min (geometric mean 688 g/min.) Glomerular filtration rate also showed a wide range, from supranormal to markedly decreased values (128 to 28 ml·min^–1· (1.73 m²)^–1, mean 75). The filtration surface (interface between capillary and urinary space) per total number of nephrons (open+occluded) was estimated by combined light- and electron microscopy. The percentage occluded glomeruli as well as structural quantities in the open glomeruli were taken into account in this estimate. A highly significant correlation was seen between glomerular filtration rate and filtration surface per nephron (r=0.77, p<10^–4). The percentage occluded glomeruli contributed significantly to the variation in glomerular filtration rate (for this relationship tested separately r=-0.78, p<10^–5). The volume of open glomeruli was even larger than that seen in early diabetic glomerular hypertrophy and tended to increase with the percentage of glomerular closure, indicating that a compensatory hypertrophy might have taken place. In the open glomeruli the filtration surface constituted a smaller percent of total capillary surface (the remaining part facing the mesangial regions) than in early diabetic patients and control subjects.Our study has demonstrated that reduced glomerular filtration surface is closely associated with reduced glomerular filtration rate in Type 1 diabetic patients with diabetic nephropathy.     

Increased kidney size,glomerular filtration rate and renal plasma flow in short-term insulin-dependent diabetics

Summary Glomerular filtration rate (GFR), renal plasma flow (RPF) and kidney volume were measured in thirteen male subjects (mean age 30 years) with short-term insulin-dependent diabetes (mean duration of disease 2.4 years) and fourteen normal male subjects (mean age 29 years). GFR and RPF were measured by constant infusion technique using I¹²⁵-iothalamate and ¹³¹I-hippuran. Kidney size was determined by means of ultrasound. GFR, RPF and kidney volume were increased in the diabetic patients compared to the normal controls, 144 versus 113 ml/ min×1.73m² (p<0.0005), 627 versus 523 ml/ min×1.73 m² (p<0.0025) and 278 versus 224 ml/ 1.73 m² (p<0.0005) respectively. Combining results from diabetic patients and controls revealed a positive correlation between kidney size and GFR (r= 0.70, p<0.001) and between kidney size and RPF (r=0.61, p<0.001). Within the groups kidney size and RPF correlated significantly in the diabetics (p< 0.01) and the same was found for kidney size and GFR (0.025< p<0.05), while no correlations were found in the normal group. GFR and RPF correlated in the diabetics when evaluated separately (r=0.81, p<0.001) and in the controls (r=0.73, p<0.001). The previous and present data suggest that the mechanisms of the elevated GFR in insulin-dependent diabetics are enhanced RPF, increased transglomerular hydrostatic pressure gradient and increased glomerular ultrafiltration coefficient. The increased kidney size is probably the main cause of the above alterations in the GFR determinants.     

血清胱抑素C与糖尿病肾病

血清胱抑素C是一种半胱氨酸蛋白酶抑制剂,由机体所有有核细胞以恒定的速率产生,其相对分子质量小,可被肾小球自由滤过,在近端肾小管被代谢.血清胱抑素C作为一种内源性标志物,可以较早的反映肾小球滤过率的变化,故其在糖尿病肾病早期诊断中有重要的价值.     

老年2型糖尿病患者肾小球滤过率的改变及影响因素分析

目的探讨老年2型糖尿病患者的肾小球滤过率(GFR)的变化特点并对其临床影响因素进行分析.方法住院的2型糖尿病人173例分为30～44岁、45～59岁及≥60岁三组进行放射性核素肾动态显像测定GFR,同时测定血肌酐、糖化血红蛋白、尿白蛋白排泄率.结果随着年龄的增加,GFR呈逐渐下降,尤以≥60岁组下降更为明显(P＜0.01),尿白蛋白排泄率也呈逐渐增加,GFR与年龄及尿白蛋白排泄率分别呈显著负相关(P＜0.001);合并高血压或/和冠心病者加速GFR下降;逐步回归分析显示年龄、尿白蛋白排泄率、高血压、冠心病是导致GFR下降的主要因素.结论老年糖尿病人在年龄等多因素作用下GFR呈显著性下降.GFR是反映老年糖尿病人肾功能变化的敏感指标.GFR与尿白蛋白排泄率联合测定能更全面地反映老年糖尿病肾病的病变程度.     

A prospective study of glomerular filtration rate and arterial blood pressure in insulin-dependent diabetics with diabetic nephropathy

Summary Glomerular filtration rate (GFR, single bolus ⁵¹Cr-EDTA technique), serum creatinine, proteinuria and arterial blood pressure have been measured prospectively in 14 young onset insulin-dependent diabetics selected by of persistent proteinuria (> 0.5 g/day) secondary to diabetic nephropathy. Twelve of the 14 patients had normal serum creatinine levels. None of the patients received antihypertensive treatment. During the mean observation period of 26 months (range 23 to 33 months) GFR decreased from 107 to 87 ml/min/1.73 m² (p< 0.001), serum creatinine remained unchanged: 107 and 112/gmmol/l (NS), proteinuria increased from 1.8 to 3.3 g/day (p<0.001) and arterial blood pressure rose from 132/88 to 153/101 mmHg (p<0.001). Glomerular filtration rate decreased linearly with time (slope=–0.75, r=0.99, p<0.001) by a mean of 0.75 ml/min/month (range 0.1 to 1.5 ml/ min/month). The decrease in GFR did not correlate with sex, age at onset, duration of diabetes, arterial blood pressure, proteinuria, insulin requirement, postprandial blood glucose or the initial GFR, but numbers were small. The decline in GFR in each individual was constant, but varied considerably between patients. Increase in arterial blood pressure to a hypertensive level is an early feature of diabetic nephropathy in young insulin-dependent diabetics.     

肾小管功能在亚临床糖尿病肾病诊断价值中的初步探讨

目的 观察2型糖尿病患者的肾小管功能,分析肾小管损伤标记物与亚临床糖尿病肾病(DN)的关系.方法 298例2型糖尿病患者根据24h尿微量白蛋白(UMA)和估算的肾小球滤过率(GFR)分为对照组(NC组,正常白蛋白尿及正常滤过率,n=100)、亚临床DN组(SDN组,正常白蛋白尿高滤过率,n =87)和早期DN组(EDN组,微量白蛋白尿,n=111).应用免疫透射比浊法检测24 h UMA、尿视黄醇结合蛋白(RBP)、尿β2-微球蛋白(β2-MG),生化法测定尿N-乙酰-D-氨基葡萄糖苷酶(NAG)、β-半乳糖苷酶(GAL),分析各组肾小管损伤标记物及其与亚临床DN的关系.结果 与NC组相比,SDN组NAG较高(x2=9.032,P＜O.01),而与EDN组差异无统计学意义;EDN组RBP水平明显高于NC组及SDN组(x2=56.341,31.955,P均＜0.01);NC组、SDN组、EDN组GAL、β2-MG水平呈升高趋势,但差异无统计学意义.与NC组相比,SDN组及EDN组近端肾小管功能异常率较高(分别为59％,82％,78.2％,x2=42.658,P＜0.01).SDN组肾小管损伤标记物中一项或两项异常者的比例高于NC组及EDN组.肾小管损伤标记物中两项异常者有发生亚临床DN的风险[优势比(OR)=2.9,P=0.005],但经校正年龄、性别、糖尿病病程、总甘油三酯、总胆固醇、高密度脂蛋白-胆固醇、糖化血红蛋白、体重指数后,差异无统计学意义(OR=1.7,P＞0.05).结论 肾小管损伤可能对早期肾功能减退的判断较肾小球损伤更重要,尿白蛋白正常但GFR升高的亚临床DN患者肾小管损伤标记物的水平升高及种类增多.     

Hypotensive therapy reduces microvascular albumin leakage in insulin-dependent diabetic patients with nephropathy

The effect of hypotensive therapy on the transcapillary escape rate of albumin (TERalb) was studied in eight hypertensive insulin-dependent diabetic patients (mean age 29, range 19-42 years) with nephropathy and retinopathy. Transcapillary escape rate of albumin (initial disappearance of intravenously injected 125I-labelled human serum albumin), urinary albumin excretion rate (radial immunodiffusion), and glomerular filtrate rate (single bolus 51-Cr-EDTA technique) were measured. After hypotensive treatment (mean duration, 23 months, range 7-39 months) with combinations of metoprolol, hydralazine, and frusemide or thiazide diuretics, arterial blood pressure fell from 152/103 +/- 18/6 mmHg (mean +/- SD) to 133/81 +/- 12/10 mmHg (p less than 0.01), transcapillary escape rate of albumin from 10.2 +/- 1.8 to 8.1 +/- 1.8% of intravascular mass of albumin/h (p less than 0.01), albuminuria from 1803 (370-5066) micrograms/min to 940 (101-2676) micrograms/min (median and range, p less than 0.05), and glomerular filtration rate from 103 +/- 23 to 84 +/- 22 ml/min/1.73 m2 (p less than 0.01). Our study suggests that effective hypotensive treatment reduces the abnormally elevated albumin leakage characteristically found in insulin-dependent diabetic patients with clinical microangiopathy. This may be due to a reduction in the hydrostatic pressure in the microcirculation.     

Estimating glomerular filtration rate in diabetes: a comparison of cystatin-C- and creatinine-based methods

Aims/hypothesis We compared the predictive performance of a GFR based on serum cystatin C levels with commonly used creatinine-based methods in subjects with diabetes.Subjects, materials and methods In a cross-sectional study of 251 consecutive clinic patients, the mean reference (plasma clearance of ^99mTc-diethylene-triamine-penta-acetic acid) GFR (iGFR) was 88±2 ml min⁻¹ 1.73 m⁻². A regression equation describing the relationship between iGFR and 1/cystatin C levels was derived from a test population (n=125) to allow for the estimation of GFR by cystatin C (eGFR-cystatin C). The predictive performance of eGFR-cystatin C, the Modification of Diet in Renal Disease 4 variable formula (MDRD-4) and Cockcroft–Gault (C–G) formulas were then compared in a validation population (n=126).Results There was no difference in renal function (ml min⁻¹ 1.73 m⁻²) as measured by iGFR (89.2±3.0), eGFR-cystatin C (86.8±2.5), MDRD-4 (87.0±2.8) or C–G (92.3±3.5). All three estimates of renal function had similar precision and accuracy.Conclusions/interpretation Estimates of GFR based solely on serum cystatin C levels had the same predictive potential when compared with the MDRD-4 and C–G formulas.