基于肌酐与胱抑素的肾小球滤过率估算方程对人群肾功能分期的评价及应用

目的 评价慢性肾脏病（CKD）流行病学协作组（CKD-EPI）2009方程、CKD-EPI2012方程及简化MDRD（modification of diet in renal disease）方程在CKD分期中的作用及对常见心血管疾病的预测价值。方法 选择2015年9-11月江苏省句容地区11 151例成年人进行问卷调查,监测血肌酐（Scr）及胱抑素（Cys-C）水平,用上述三种方程评估肾小球滤过率（GFR）。结果 对慢性肾功能不全者,在判断肾功能分期上,CKD-EPI（2009、2012）方程均与MDRD方程有较好一致性（P<0.001）,其中CKD-EPI2012方程与CKD-EPI2009方程判断结果有极高一致性。而在无慢性肾病史人群中,MDRD、CKD-EPI2012方程均与CKD-EPI2009方程判断肾功能分期结果有较高一致性（P<0.001）,Kappa值分别为0.662和0.654;CKD-EPI2012方程与MDRD方程分期结果仅有中度一致性。在所有研究对象中,采用Bland-Altman方法分析,MDRD方程、CKD-EPI2009方程与CKD-EPI2012方程对CKD分期结果具有较好的一致性。≥ 70岁人群中CKD-EPI（2009、2012）方程与MDRD方程对CKD分期的一致性高于<70岁人群,且男性高于女性。CKD-EPI（2009、2012）方程计算GFR预测高血压的AUC值高于MDRD方程预测结果;CKD-EPI2012方程计算GFR预测脑卒中和冠心病的AUC值均高于MDRD方程预测结果,而CKD-EPI2009方程与MDRD方程计算的GFR预测结果的差异无统计学意义。结论 MDRD方程与CKD-EPI（2009、2012）方程对CKD分期结果具有中高度一致性,但后者估算的GFR对心血管预测价值高于前者。     

The effect of transfer to adult transplant care on kidney function and immunosuppressant drug level variability in pediatric kidney transplant recipients

Adolescent age at time of transplant has been recognized as a risk factor for renal allograft loss. Increased risk for graft failure may persist from adolescence to young adulthood. Transfer of care is hypothesized as a risk factor for non‐adherence and graft loss. We explored whether kidney allograft function declined at an accelerated rate after transfer of care to adult transplant centers and whether coefficient of variation of tacrolimus (CV TAC) trough levels predicted allograft loss. Single‐center, retrospective chart review was performed for pediatric kidney transplant recipients who received transplants between 1999 and 2011. Change in eGFR pre‐ and post‐transfer was performed via a linear mixed‐effects model. CV TAC was calculated in transplant recipients with TAC data pre‐ and post‐transfer. t test was performed to determine the difference between means of CV TAC in subjects with and without allograft loss following transfer of care. Of the 138 subjects who transferred to adult care, 47 subjects with data pre‐ and post‐transfer demonstrated a decrease in the rate of eGFR decline post‐transfer from 8.0 mL/min/1.73 m² per year to 2.1 mL/min/1.73 m² per year, an ~80% decrease in eGFR decline post‐transfer (P = 0.01). Twenty‐four subjects had CV TAC data pre‐ and post‐transfer of care. Pretransfer CV TAC for subjects with allograft loss post‐transfer was significantly higher than in subjects without allograft loss (49% vs 26%, P < 0.05). Transfer of care was not independently associated with acceleration in eGFR decline. CV TAC may aid in identifying patients at risk for allograft loss post‐transfer.     

老年患者血清SOD水平与心肾功能的关系

目的 了解老年患者血清超氧化物歧化酶（superoxide dismutase, SOD）水平,探讨血清SOD与心肾功能的关系。方法 采用横断面调查研究方法,连续纳入符合观察条件的老年患者860例,进行人体测量和生活方式调查,检测血清SOD水平、脑钠肽（brain natriuretic peptide, BNP）、C-反应蛋白（C-reactive protein, CRP）、白蛋白（albumin, Alb）等生化指标,应用Logistic回归法分析血清SOD水平与心肾功能的关系。结果 以血清SOD四分位水平分析各临床指标,发现随着年龄、CRP和BNP水平的升高（F=38.443,P＜0.001;χ2=75.169,P＜0.001;F=39.019,P＜0.001）和血清Alb水平、肾功能的下降（F=137.415,P＜0.001;F=28.037,P＜0.001）,血清SOD水平呈下降趋势。与高四分位血清SOD水平比较,校正年龄、性别和传统风险因素后,第2四分位和第1四分位SOD水平发生心功能不全的风险增加（OR=1.86,95%CI： 1.18～2.92;OR=3.15,95%CI： 1.95～5.08）;继续校正血清Alb后,只有第1四分位SOD水平心功能不全的风险增加（OR=1.90,95%CI： 1.11～3.27）;进一步校正CRP后,第1四分位心功能不全风险较弱（OR=1.79,95%CI： 1.00～3.19）。与高四分位血清SOD水平比较,校正年龄、性别和传统风险因素后,第2四分位和第1四分位SOD水平发生肾功能不全的风险增加（OR=2.43,95%CI： 1.51～3.90;OR=2.86,95%CI： 1.77～4.63）;继续校正Alb和CRP水平后,第2四分位和第1四分位SOD水平发生肾功能不全的风险进一步增加（OR=3.14,95%CI： 1.82～5.40;OR=4.21,95%CI： 2.30～7.70）。结论 老年人血清SOD水平随着年龄增加呈下降趋势;血清SOD水平下降与心肾功能降低有关,是影响肾功能的重要因素。     

The measured glomerular filtration rate (mGFR) before and 6 months after bariatric surgery: A pilot study

IntroductionOver the last few decades, the prevalence of obesity has increased dramatically. This increase has been mirrored by a rise in the risk of a number of health conditions, including hypertension, diabetes and chronic kidney disease. Although the weight loss following bariatric surgery has been shown to relieve the severity of diabetes and reduce hypertension, the effect on renal function has been less extensively evaluated.ObjectiveThe aims of the present study were to: (i) compare the estimated glomerular filtration rate (eGFR, using the MDRD and CKD-EPI equations) and the calculated glomerular filtration rate (using the 24-hour urine volume) with the measured glomerular filtration rate (mGFR) assessed with the plasma iohexol clearance method in severely obese patients, and (ii) evaluate the effect of weight loss on the mGFR 6 months after bariatric surgery.MethodsBefore and six months after bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy), eligible patients for bariatric surgery were admitted as day cases to the nephrology unit, where they underwent a plasma iohexol clearance test. The GFR was also estimated using the MDRD and CKDEPI equations and the 24-hour urine method. Changes in eGFR and mGFR were compared using a Wilcoxon test for paired data.ResultsData from 16 patients with severe obesity (mean ± standard deviation of Body Mass Index [BMI]: 43.9 ± 7.3 kg/m²) were analyzed. At baseline, 12 (75%) presented with hypertension and 10 (63%) presented with diabetes. The median [range] iohexol clearance rate was 109 [57–194] mL/min. The plasma iohexol clearance test evidenced hyperfiltration (mGFR > 120 mL/min) in 7 patients. In contrast, the eGFR values generated by the MDRD equation, the CKDEPI equation and the GFR MFR calculated with the 24-hour urine method only identified hyperfiltration in 1, 0 and 5 patients, respectively. Six months after surgery, the mean BMI had fallen significantly (P < 0.0012), and the severity of diabetes (according to the HbA_1c level) had decreased significantly from 6.6 [6.0–9.8] % to 5.7 [5.2–8.6] % (P = 0.025). The iohexol clearance rate increased slightly after bariatric surgery. Changes in BMI after surgery do not seem to be correlated with the changes in iohexol clearance. In patients displaying hyperfiltration at baseline, the mGFR fell significantly (n = 7; P = 0.01) and returned to near normal values. No significant changes in the eGFR were observed.ConclusionOur results suggest that MDRD and CKD-EPI equations do not provide accurate estimates of the true GFR in severely obese patients (particularly in those with hyperfiltration). Iohexol clearance or other methods for determining mGFR should constitute the gold standard for the accurate evaluation of renal function in this context. Renal function (as evaluated by the mGFR) improved 6 months after bariatric surgery in severely obese individuals particularly in patients displaying hyperfiltration at baseline. However, these observations must be confirmed in a larger study with a longer follow-up period.     

不同程度慢性乙型肝炎患者肾功能评估及危险因素分析

目的 对不同程度慢性乙型肝炎（CHB）患者肾功能进行评估,分析正规抗病毒治疗对CHB患者肾功能的影响,分析CHB患者肾功能损伤的危险因素。方法 收集2015年1月至2016年4月于安徽医科大学第一附属医院379例CHB患者,按照CHB临床分度将患者分为轻度组（191例）、中度组（123例）、重度组（65例）3组,采用简化MDRD方程计算CHB患者肾小球滤过率（eGFR）。分析不同程度CHB患者肾功能有无差异,正规抗病毒治疗对不同程度CHB患者肾功能的影响及年龄、性别、HBeAg、HBV DNA等对CHB患者肾功能的影响。结果 轻度组患者eGFR水平为（73.10±14.42）mL/（min·1.73m²）,中度组患者eGFR水平为（65.17±11.42）mL/（min·1.73m²）,重度组患者eGFR水平为（59.72±18.59）mL/（min·1.73m²）,3组间eGFR水平差异具有统计学意义（F=25.200,P=0.000）;CHB患者肝炎病情程度和年龄是引起CHB患者出现肾功能损伤的危险因素（P<0.05）。结论 CHB患者eGFR水平与病情程度相关,轻度和中度正规抗病毒治疗的CHB患者eGFR水平较未正规抗病毒治疗者eGFR水平高,肝炎病情程度与年龄是引起CHB患者出现肾功能损伤的危险因素。