慢性肾脏病定义及分期系统修订的进展——2012-KDIGO慢性肾脏病临床管理实践指南解读

慢性肾脏病（CKD）是全球性公共卫生问题,自2002年美国国家肾脏基金会（NKF）所属“肾脏病预后质量倡议”（K/DOQI）工作组提出了CKD的定义和分期标准以来,该指南对提高全球CKD患者的诊断、治疗水平及改善预后发挥了重大作用。但是,大量根据K/DOQI-CKD诊断标准进行的临床和流行病学研究证据使人们对于CKD患病率过高、CKD3期比例过高、老年人患病率过高以及肾脏单纯结构异常是否应诊断CKD等诸多问题产生了困惑,继而引发了关于现行定义和分期系统适宜性的争议。对此,国际肾脏病组织“改善全球肾脏病预后组织”（KDIGO）于2012年颁布新指南,调整了CKD的定义,建立了考虑病因、肾小球滤过率（GFR）和尿白蛋白水平的CKD联合分期系统（CGA系统）,制定了危险分层模型以判断预后,推荐应用CKD-EPI公式估算GFR水平等。     

Cardiovascular Disease Assessment Prior to Kidney Transplantation

Cardiovascular disease is highly prevalent and the leading cause of mortality in patients with chronic kidney disease, end-stage kidney disease, and kidney transplantation. However, kidney transplantation offers improved survival and quality of life, with an overall reduction in cardiovascular disease events; therefore, it remains the optimal treatment choice for those with advanced kidney disease. Pretransplantation cardiovascular assessment is performed prior to wait-listing and at routine intervals with the principal goal of screening for asymptomatic cardiac disease, intervening when necessary to improve long-term patient and allograft survival. Current clinical practice guidelines are based on expert opinion, with a lack of high-quality evidence to guide standardized screening practices. Recent studies support de-escalation in screening with avoidance of preemptive revascularization in asymptomatic patients, but they fail to provide clear guidance on how best to assess the cardiovascular fitness of this high-risk group. Herein we summarize current practice guidelines, discuss key study findings, highlight the role of optimal medical therapy, and evaluate future directions for cardiovascular disease assessment in this population.     

他汀类药物,从心血管疾病到肾脏病

随着他汀类药物在临床上的广泛应用,其降脂和各种降脂外作用能在很大程度上减少心血管事件发生的风险;同时,人们也对他汀类药物在慢性肾脏疾病中的肾保护作用产生了浓厚的兴趣,开展了一系列的试验研究来揭示他汀类药物的多效性,现就此做一综述。     

中国终末期肾脏疾病的现状问题和对策

慢性肾脏病(CKD)和终末期肾脏疾病(ESRD)的防治已经成为中国重要的公共卫生问题。文章概括介绍中国CKD和ESRD的现状、危害以及防治中的问题,简述了中华医学会肾脏病学分会做出的工作,提出了今后防治ESRD的对策。目的在于提高社会、政府、公众以及医务人员对防治ESRD迫切性的认识,提高中国ESRD防治水平。     

慢性肾脏疾病的心血管并发症及其处理

心血管疾病是慢性肾脏疾病的重要并发症及透析患者的重要死亡原因,重视心血管疾病预防和治疗对改善慢性肾脏疾病患者的预后具有极重要的意义。现就近年来慢性肾脏疾病并发心血管疾病的流行病学情况、临床预后及相关处理等问题作一简要综述。     

Rapid decline in estimated glomerular filtration rate is common in adults with sickle cell disease and associated with increased mortality

We evaluated the prevalence of rapid decline in kidney function, its potential risk factors and influence upon mortality in sickle cell disease (SCD) in a retrospective single-center study. Rapid decline of kidney function was defined as estimated glomerular filtration rate (eGFR) loss of >3·0 ml/min/1·73 m² per year. A multivariable logistic regression model for rapid eGFR decline was constructed after evaluating individual covariates. We constructed multivariate Cox-regression models for rapid eGFR decline and mortality. Among 331 SCD patients (median age 29 years [interquartile range, IQR: 20, 41]; 187 [56·5%] female) followed for median 4·01 years (IQR: 1·66, 7·19), rapid eGFR decline was noted in 103 (31·1%). History of stroke (odds ratio [OR]: 2·91, 95% confidence interval [CI]: 1·25–6·77) and use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (OR: 3·17, 95% CI: 1·28–7·84) were associated with rapid eGFR decline. The rate of eGFR change over time was associated with mortality (hazard ratio [HR]: 0·99, 95% CI: 0·984–0·995, P = 0·0002). In Cox-regression, rapid eGFR decline associated with mortality (HR: 2·07, 95% CI: 1·039–4·138, P = 0·04) adjusting for age, sex and history of stroke. Rapid eGFR decline is common in SCD and associated with increased mortality. Long-term studies are needed to determine whether attenuating loss of kidney function may decrease mortality in SCD.     

Assessment and management of hypertension in patients with type 2 diabetes

Background: Hypertension is a major risk factor for adverse outcomes in type 2 diabetes and an important target for intervention. Despite this, the management of blood pressure (BP) remains suboptimal, particularly in patients at increased risk for cardiovascular and chronic kidney disease. The aim of this study was to estimate the frequency of hypertension and its management in consecutive clinic‐based samples of patients with type 2 diabetes in Australian primary care. Methods: BP levels and antihypertensive management strategies were compared in patients with type 2 diabetes recruited as part of the Developing Education on Microalbuminuria for Awareness of reNal and cardiovascular risk in Diabetes (DEMAND) study in 2003 (n = 1831) and the National Evaluation of the Frequency of Renal impairment cO‐existing with Non‐insulin‐dependent diabetes (NEFRON) study in 2005 (n = 3893). Systolic BP levels and the use of antihypertensive therapies were examined in patients with and without chronic kidney disease. Results: The patient characteristics in both studies were similar in that more than 80% of patients in both studies were hypertensive. Systolic BP targets of ≤130 mmHg were achieved in approximately half of all treated patients in both studies. However, the use of antihypertensive therapy either alone or in combination increased from 70.4% in DEMAND to 79.5% in NEFRON 2 years later (P < 0.001). Despite this, antihypertensive therapy continued to be underutilized in high‐risk groups, including in those with established chronic kidney disease. Conclusion: The DEMAND and NEFRON studies both show that BP control is achievable in Australian general practice, with more than half of all patients seeing their general practitioners achieving a target systolic BP ≤130 mmHg. However, more needs to be done to further reduce BP levels, particularly in patients at high risk of adverse outcomes.     

Association of BP with Death,Cardiovascular Events,and Progression to Chronic Dialysis in Patients with Advanced Kidney Disease

Background and objective

The optimal BP target to reduce adverse clinical outcomes in patients with CKD is unclear. This study examined the relationship between BP and death, cardiovascular events (CVEs), and kidney disease progression in patients with advanced kidney disease.

Design, setting, participants, & measurements

The relationship of systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) with death, CVE, and progression to long-term dialysis was examined in 1099 patients with advanced CKD (eGFR≤30 ml/min per 1.7 3m²; not receiving dialysis) who participated in the Homocysteine in Kidney and ESRD study. That study enrolled participants from 2001 to 2003. Cox proportional hazard models were used to examine the association between BP and adverse outcomes.

Results

The mean±SD baseline eGFR was 18±7 ml/min per 1.73 m². During a median follow-up of 2.9 years, 453 patients died, 215 had a CVE, and 615 initiated long-term dialysis. After adjustment for demographic characteristics and confounders, SBP, DBP, and PP were not associated with a higher risk of death. SBP and DBP were also not associated with CVE. The highest quartile of PP was associated with a substantial higher risk of CVE compared with the lowest quartile (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.10 to 2.52). The highest quartiles of SBP (HR, 1.28; 95% CI, 1.01 to 1.61) and DBP (HR, 1.36; 95% CI, 1.07 to 1.73), but not PP, were associated with a higher risk of progression to long-term dialysis compared with the lowest quartile.

Conclusions

In patients with advanced kidney disease not undergoing dialysis, higher PP was strongly associated with CVE whereas higher SBP and DBP were associated with progression to long-term dialysis. These results suggest that SBP and DBP should not be the only factors considered in determining antihypertensive therapy; elevated PP should also be considered.