基于肌酐和胱抑素C的肾小球滤过率评估公式判断2型糖尿病肾病患者的预后  

Prediction of renal outcome by estimating GFR from a combination of serum creatinine and cystatin C in type 2 diabetic nephropathy

作　　者：潘瑜[1] 蒋松[1] 邱丹丹[1] 施劲松[1] 周敏林[1] 安玉[1] 葛永纯[1] 谢红浪[1] 刘志红[1] 

机构地区：[1]南京大学医学院附属金陵医院、国家肾脏疾病临床医学研究中心,全军肾脏病研究所,南京210016

出　　处：《肾脏病与透析肾移植杂志》2016年第2期107-112,133,共7页Chinese Journal of Nephrology,Dialysis & Transplantation

基　　金：国家自然科学基金青年基金(81500548);国家科技支撑计划课题(2015BAI12B05)

摘　　要：目的:比较三种肾小球滤过率(GFR)计算方法(e GFRcre、e GFRcys与e GFRcre-cys)评价2型糖尿病肾病(T2DN)患者肾功能的准确性及判断预后的临床价值。方法:纳入随访登记数据库中T2DN患者501例,通过横断面分析,比较0、12、24月时用e GFRcre、e GFRcys与e GFRcre-cys公式计算得到e GFR的分布及偏移状态,并随访观察12月和24月时不同e GFR下降幅度(20%、30%、40%和57%)对判断患者肾脏终点事件的敏感性和特异性。结果:将e GFRcre-cys设为参考,e GFRcre公式会高估GFR水平,在e GFRcre-cys>120 ml/(min·1.73m^2),90~120 ml/(min·1.73m^2),60~89 ml/(min·1.73m^2),30~59 ml/(min·1.73m^2),<30 ml/(min·1.73m^2)的T2DN患者中,中位偏移分别为-0.21 ml/(min·1.73m^2),6.17 ml/(min·1.73m^2),12.69 ml/(min·1.73m^2),9.55 ml/(min·1.73m^2),5.27 ml/(min·1.73m^2)。低龄、高收缩压、低体质指数(BMI)和高血糖增加偏移度。基于e GFRcre-cys公式24月的GFR下降速率较e GFRcre和e GFRcys公式更好的判断肾脏终点,曲线下面积(ROC)分别为0.857±0.029 7,0.839±0.031 9和0.796±0.035 7。24月的e GFRcre-cys下降速率联合基线e GFRcrecys的GFR水平可有效判断肾脏预后,ROC达0.917±0.017 8。基线e GFRcre-cys≥90 ml/(min·1.73m^2)的患者,以e GFRcre-cys 24月下降57%作为判断指标,敏感性和特异性均为100%;基线e GFRcre-cys<90 ml/(min·1.73m^2)的患者,以e GFRcre-cys 24月下降40%作为判断预后指标,其准确性更好。结论:e GFRcre公式可能高估T2DN患者的GFR,尤其在e GFR 60~120 ml/(min·1.73m^2)的患者。以e GFRcre-cys公式计算的24月GFR下降57%和40%分别用于判断基线e GFRcre-cys≥90 ml/(min·1.73m^2)和<90 ml/(min·1.73m^2)的T2DN患者肾脏预后的敏感度和特异度较好。Objective： To investigate estimated GFR from combination of serum creatinine and cystatin C as marker to predict long-term renal outcome in patient with Type 2 diabetic nephropathy（ DN）. Methodology： Five hundred one patients with DN were enrolled in this study. The levels of e GFRcre,e GFRcys,e GFRcrecys were assessed at baseline,12,and 24 month. After the follow-up time of median 31 months,the end-stage renal disease（ ESRD） risk related to percentage change in estimated GFR over one and 2 years were compared to the three equations. Results：compared with e GFRcrecys,e GFRcre overestimated GFR in DN. The absolute bias was- 0. 21,6. 17,12. 69,9. 55,5. 27 ml /（ min·1. 73m^2） when e GFRcrecys 〉120 ml/（ min·1. 73m^2）,90 ~ 120 ml/（ min·1. 73m^2）,60 ~ 89 ml/（ min·1. 73m^2）,30 ~ 59 ml/（ min·1. 73m^2）, 〈30 ml/（ min·1. 73m^2）,respectively. Lower age,higher systolic blood pressure,lower body mass index,and increased fast blood glucose contributed to the bias. e GFRcrecys slope over 2 year was superior to e GFRcre or e GFRcys to predict renal outcome,whose area under curve（ AUC） was 0. 857 ± 0. 029 7 and the ROC of e GFRcrecys slope over 2 year combined with baseline e GFRcrecys was further increased to 0. 917 ± 0. 0178. Baseline e GFRcrecys ≥90 ml /（ min·1. 73m^2）,57% reduction over 2 years as an alternative end point,the sensitivity and specificity was 100%; Baseline e GFRcrecys 〈90 ml /（ min·1. 73m^2）,40% reduction over 2 years could be an idea alternative end point. Conclusion： e GFRcre overestimated GFR in the patients with DN,in particular e GFR less than120 ml /（ min·1. 73m^2）,57% reduction over 2 years in baseline e GFRcrecys ≥90 ml/（ min·1. 73m^2） and 40% reduction over 2 years in baseline e GFRcrecys 〈90 ml /（ min·1. 73m^2） could be an idea alternative end point to predict ESRD.

关 键 词：胱抑素C 肾小球滤过率 糖尿病肾病 CKD-EPI公式 预后 

分 类 号：R587.2[医药卫生—内分泌] R692.9[医药卫生—内科学]