最新KDIGO急性肾损伤指南在新月体肾炎中的应用

目的 分析2012年国际改善全球肾脏病预后组织（KDIGO）发表的急性肾损伤（AKI）和急性肾脏病（AKD）定义在不同类型的新月体肾炎中的应用.方法 2009年1月至2012年12月在北京大学第一医院肾内科住院接受肾活检其光镜病理检查超过50％肾小球内有新月体形成的患者.根据2012年KDIGO指南AKI/AKD的定义,以血肌酐（Scr）和24h尿量为指标将入选的患者分为AKI组,非AKI的AKD组,非AKD组和无法分类组.结果 AKD能够识别84.2％的新月体肾炎患者,而AKI仅能识别61.4％的患者.对于不同类型的新月体肾炎,AKI识别抗GBM抗体型最高,达91％.新月体性肾小球肾炎较肾小球肾炎伴多数新月体形成更易被AKI识别（P =0.002）.不同成分为主的新月体肾炎,AKI/AKD的识别无统计学差异.结论 2012年KDIGO AKD的定义比AKI更能够早期识别急性肾功能不全的患者.     

International statistical classification of diseases and related health problems coding underestimates the incidence and prevalence of acute kidney injury and chronic kidney disease in general medical patients

Background

The international classification of diseases (ICD) code is frequently used to identify renal impairment in epidemiological research. However, Australian studies examining accuracy of this administrative data in coding kidney injury are lacking.

Aims

To compare the ICD 10 coding with the kidney disease: improving global outcomes (KDIGO) criteria in diagnosing acute kidney injury (AKI) and/or chronic kidney disease (CKD).

Methods

A retrospective study of 325 patients admitted to general medicine during January 2012 was performed. Sensitivity and specificity of ICD 10 in identifying AKI and CKD were calculated using KDIGO as gold standard.

Results

The sensitivities of ICD 10 in identifying AKI and CKD were low for both (59.5% and 54.1%), but the specificities were high (86.2% and 90.2%). Using KDIGO criteria, we identified 72 AKI (22%), 56 CKD (17%), 64 AKI on CKD (19%) and 133 controls (40%). Compared to the control group, patients with AKI and AKI on CKD had longer length of stay (3.2 vs 4.9 days and 3.2 vs 4.8 days, P = 0.20). Renal impairment groups had increased in‐hospital mortality rate (5% control, 6% AKI, 10% CKD, 9% AKI on CKD) and re‐admission rate within 30 days (13% control, 20% AKI, 25% CKD, 26% AKI on CKD). After adjusting for age, gender and comorbidities, the difference in outcomes was not statistically significant.

Conclusion

This study shows that ICD 10 fails to identify almost half of the patients with AKI (40.5%) and CKD (45.9%) in our cohort. A total of 60% had evidence of renal impairment as defined by KDIGO.     

《KDIGO临床实践指南:肾移植受者的诊治》免疫抑制部分对我们的启示

《KDIGO临床实践指南:肾移植受者的诊治》是肾移植领域第一个基于循证医学证据的临床实践指南,兼顾了不同国家经济、医疗水平的差异,对我国肾移植临床工作有较高的借鉴价值。我们从其中免疫抑制部分体会到以下几点:应重视我国肾移植领域循证医学证据的积累;重视免疫抑制剂的性价比及个体化用药,降低治疗费用;此外也应重视移植肾活组织检查,提高临床诊治水平。