GFR评估方法比较及GFR影响因素分析

发布时间：2018-03-14 13:17

本文选题：血肌酐　切入点：胱抑素C　出处：《南方医科大学》2017年博士论文　论文类型：学位论文

【摘要】：研究背景:慢性肾脏病(CKD)广泛流行,已经成为严重的全球性公共卫生问题,给社会及患者家庭造成沉重的经济负担。慢性肾小球肾炎是我国发生CKD的主要致病因素,但随着2型糖尿病(T2DM)患者的日益增多,后者有可能成为CKD的主要病因。及早发现肾功能异常,明确致病因素并进行针对性治疗,有利于防止肾功能恶化。肾小球滤过率(GFR)是评估肾功能的重要指标之一,不同滤过方程式在临床应用上有各自的特点,本研究旨在通过3个肾脏病膳食改良试验(MDRD)滤过方程式、3个慢性肾脏病流行合作组(CKD-EPI)滤过方程式获得的估算肾小球滤过率(eGFR)与99m锝-二乙烯三胺五乙酸(99Tcm-DTPA)肾动态显像获得的参考肾小球滤过率(rGFR)进行对比研究,进一步指导临床实践。目的:探讨 eGFR(CKD-EPIscr、CKD-EPIcys、CKD-EPlscr_cys、简化 MDRD、中国改良简化MDRD、原始MDRD)在我国CKD患者以及T2DM患者GFR评估中的准确性及其在CKD分期中的应用价值;分析不同因素对T2DM患者GFR的影响。方法:1422例CKD患者(第一部分),403例T2DM患者(第二部分),以及T2DM组中234例患者(第三部分)纳入本次研究。通过3个MDRD、3个CKD-EPI滤过方程式计算eGFR并与rGFR进行对比分析,同时对可能影响T2DM患者是否罹患慢性肾功能不全,以及CKD分期的相关因素进行logistic回归分析。结果:血肌酐、胱抑素C与rGFR之间存在密切相关,拟合曲线呈幂模型。Bland-Altman 一致性分析表明,在CKD组及T2DM组,eGFR_(cys)误差范围绝对值最小,分别为63.3、64.0;eGFR_(scr)_cys误差范围绝对值分别为63.4、64.8,与eGFR_(cys)相接近,但eGFR_(scr)_cys与rGFR之间的偏差更小。在CKD组及T2DM组,eGFR_(cys)与rGFR之间30%、50%的符合率最高,分别为54.4%、78.9%及61.5%、87.8%,eGFR_(scr)_cys 次之,30%、50%的符合率分别为 51.6%、76.4%及 58.6%、85.1%。在以血肌酐为变量的滤过方程式中,eGFR_(scr)在CKD组和T2DM组与rGFR的一致性优于其它血肌酐滤过方程式(MDRD)。在两组患者中,eGFR_(scr)_cys在诊断慢性肾功能不全上具有良好的诊断效能,ROC60曲线下面积最大,分别为0.951、0.942,且在此条件下诊断慢性肾功能不全的切点值分别为58.1 ml/min/1.73 m~2、57.2 ml/min/1.73 m~2,与目前临床慢性肾功能不全的诊断标准(60.0ml/min/1.73 m~2)相接近。各亚组eGFR在CKD组及T2DM组具有相似的临床分期表现:在CKD5期,除eGFR_MDRD(78.9%)外,其它亚组均具有较高的分期准确性(≥84.2%);血肌酐滤过方程式对G1期患者的分期准确性(≥90.4%)明显高于胱抑素C或两者联合的滤过方程式(72.5～84.5%);在其它分期各亚组具有弱～中等的分期准确性。总体分期上,在CKD组,eGFR_(scr)_cys与rGFR的分期一致性最高,kappa值为0.416;在T2DM≥18岁组,eGFRa_MDRD与rGFR的分期一致性最高,kappa值为0.417,eGFR_(scr)_cys次之,kappa值为0.404,但在T2DM 18～65岁组,eGFR_(scr)_cys滤过方程式kappa值最高,为0.423。CKD-EPI滤过方程式在T2DM患者不同年龄阶段均优于MDRD滤过方程式,但在高龄组(65岁)各滤过方程式的诊断效能波动较大。T2DM患者中,体重指数、血肌酐、胱抑素C是患者发生慢性肾功能不全的负性影响因素;年龄在血肌酐组是负性影响因素,但在胱抑素C组表现不明显;高密度脂蛋白是防止发生慢性肾功能不全的保护因素。患者年龄、体重指数、血肌酐、胱抑素C水平与T2DM患者CKD分期有关,尿酸仅在血肌酐组影响T2DM患者的CKD分期。结论:CKD-EPI_(scr_cys)与rGFR之间的一致性高、偏差最小,同时对慢性肾功能不全具有良好的诊断价值及相对较高的CKD分期准确性。在T2DM患者不同年龄组中,CKD-EPI滤过方程式与rGFR的一致性优于MDRD滤过方程式,但年龄对CKD-EPI、MDRD滤过方程式的诊断效能存在影响。除血肌酐、胱抑素C外,仍存在其它一些导致患者罹患慢性肾功能不全及影响患者CKD分期的影响因素。
[Abstract]:Background: chronic kidney disease (CKD) is widely popular, has become a serious global public health problem, causing heavy economic burden to the society and family. In patients with chronic glomerulonephritis is a major risk factor for the incidence of CKD in our country, but with type 2 diabetes mellitus (T2DM) patients is increasing, which is likely to become a major the etiology of CKD. Early detection of abnormal renal function, clear pathogenic factors and targeted therapy, can prevent the deterioration of renal function. The glomerular filtration rate (GFR) is one of the important indexes for evaluating the renal function, different filtration equations have their own characteristics in clinical application, this research aims at the 3 modification of diet in renal disease test (MDRD) filtration equation, 3 chronic kidney disease (CKD-EPI) epidemic cooperative group obtained filtration equation to estimate glomerular filtration rate (eGFR) and 99m Tc two ethylene three amine five acetic acid (99Tcm-DTPA) renal dynamic Imaging reference glomerular filtration rate (rGFR) were studied, further guide clinical practice. Objective: To investigate the effect of eGFR (CKD-EPIscr, CKD-EPIcys, CKD-EPlscr_cys, China simplified MDRD, modified abbreviated MDRD, original MDRD) in Chinese CKD patients and T2DM patients with GFR rating accuracy in estimation and its application value in CKD stage; analysis of the influence of different factors on T2DM in patients with GFR. Methods: 1422 cases of CKD patients (the first part), 403 cases of T2DM patients (section second), and 234 cases of group T2DM (third) were included in the study. By 3 MDRD, 3 CKD-EPI eGFR filtration equation calculation and comparative analysis with rGFR at the same time, the possible effect of T2DM whether patients suffering from chronic renal insufficiency, and related factors of CKD staging were analyzed by logistic regression analysis. Results: the serum creatinine, there is closely related between cystatin C and rGFR, a power curve model. Bland-Altman consistency analysis showed that in the CKD group and T2DM group, eGFR_ (Cys) error range of minimum absolute value, respectively 63.3,64.0; eGFR_ (SCR) _cys error absolute value was 63.4,64.8, and eGFR_ (Cys) to eGFR_ (SCR), but a smaller deviation between _cys and rGFR in CKD group. And group T2DM (Cys), eGFR_ and rGFR between the 30%, the 50% highest coincidence rate were 54.4%, 78.9% and 61.5%, 87.8%, eGFR_ (SCR) _cys, 30%, 50%, the coincidence rate was 51.6%, 76.4% and 58.6%, 85.1%. in the filtration equation of variable type in serum creatinine. EGFR_ (SCR) in consistency is better than that of CKD group and T2DM group and other rGFR serum creatinine filtration equation (MDRD). In the two group, eGFR_ (SCR) _cys in the diagnosis of chronic renal insufficiency has good diagnostic performance, the area under the ROC60 curve, respectively 0.951,0.942, chronic renal failure full cut and in this condition diagnosis There were 58.1 ml/min/1.73 m~2,57.2 ml/min/1.73 m~2, and the current clinical diagnostic criteria of chronic renal insufficiency (60.0ml/min/1.73 m~2) are close. Each sub group eGFR has similar clinical staging in CKD group and T2DM group showed: in CKD5 phase, except eGFR_MDRD (78.9%), the other sub group has higher accuracy of staging (more than 84.2%); the blood creatinine filtration equation on the staging of G1 patients (aged 90.4%) was significantly higher than that of cystatin C or a combination of both the filtration equation (72.5 ~ 84.5%); in the other stages of each subgroup with weak and medium stage. The overall accuracy of staging, in group CKD, eGFR_ and _cys (SCR) rGFR is the highest stage of consistency, kappa value is 0.416; in T2DM more than 18 years old group, eGFRa_MDRD and rGFR is the highest stage of consistency, the kappa value is 0.417, eGFR_ (SCR) _cys, kappa value is 0.404, but in T2DM 18~65 group, eGFR_ (SCR) _cys filtration equation Type kappa is the highest, 0.423.CKD-EPI equation was better than MDRD filtration filtration equation in different age patients with T2DM, but in the elderly group (65 years old) the filtration equation diagnostic performance fluctuations in the.T2DM patients, body mass index, serum creatinine, Cystatin C is the negative influence factors of chronic renal insufficiency in patients with age; is the negative influence factors in the blood group, but in C group showed no obvious cystatin; high density lipoprotein is a protective factor to prevent the occurrence of chronic renal insufficiency patients. Age, body mass index, serum creatinine, Cystatin C level in patients with T2DM CKD stage, only uric acid in serum creatinine in patients with T2DM group CKD staging. Conclusion: CKD-EPI_ (scr_cys) rGFR consistency between the high and the minimum deviation of chronic renal insufficiency has good diagnostic value and relatively high accuracy in CKD stage T2DM patients at different ages. In the group, is more consistent than the MDRD equation CKD-EPI equation and rGFR filtration filtration, but the age of CKD-EPI, influence the diagnostic efficacy of MDRD filtration equation. In addition to serum creatinine, Cystatin C, there are still some other causes of chronic renal insufficiency and influence factors in patients with stage CKD patients.

【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R692

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