Hnub Nyoog Thiab EGFR-raws li Risk For Adverse Clinical Outcomes
Sep 14, 2023
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Txawm hais tias tus txheeb ze pheej hmoo ntawm lub raum tsis ua haujlwm nce nrog ntau duamob raum mob hnyav(CKD) ywj siab ntawm lub hnub nyoog, nrog rau cov laus laus lub meej risk ntawm lub raum tsis ua haujlwmntawm ib lub sij hawm lub qab ntug yuav me me. Hauv tsab xov xwm no, peb thawj zaug tshuaj xyuas qee qhov kev ntsuas kev sib kis ntawm qhov tshwm sim tshwm sim (tus nqi tiag tiag lossis kev pheej hmoo) thiab kev koom tes (kev ntsuas txheeb ze: qhov sib txawv lossis qhov sib piv ntawm cov nqi lossis kev pheej hmoo). Peb hais ntxiv tias cov kev ntsuas txheeb ze yuav tsum tau nthuav tawm nrog rau kev ntsuas meej kom nkag siab thiab qhov kev pheej hmoo tsis muaj txiaj ntsig yog qhov muaj txiaj ntsig ntau dua li qhov tseeb thaum txiav txim siab kho mob. Peb mam li siv cov ntsiab cai no rau kev sib tham ntawm qhov tseeb thiab txheeb ze tus nqi lossiskev pheej hmoo ntawm lub raum tsis ua haujlwmthiab tuag thoob plaws pawg ntawm kwv yeesglomerular pom tus nqi thiab hnub nyoog. Thaum kawg, peb tham txog qhov cuam tshuam ntawm cov kev tshawb fawb uas twb muaj lawm txog seb lub ntsiab lus ntawm CKD yuav tsum suav rau hnub nyoog li cas.
Ntsiab lus:hnub nyoog,mob raum mob, raum tsis ua haujlwm, kev tuag, kev pheej hmoo
Qhov tshwm sim ntawm cov kab mob raum ntev (CKD) hauv cov pej xeem sawv daws nce nrog hnub nyoog, los ntawm 4% thaum muaj hnub nyoog<40 years to 47% at age 70 years and older [1], as do more severe CKD stages, characterized by lower estimated glomerular filtration rate (eGFR) and worse outcomes [2]. Understanding how age may modify the association between eGFR and adverse outcomes in people with CKD is not straightforward. In a large meta-analysis of over 2 million participants from the CKD Prognosis Consortium (CKDPC) [3], with older age the curve of the hazard ratios for mortality associated with a progressively lower eGFR versus a reference of 80 mL/min/1.73 m2 increased less steeply, while the curve of the absolute mortality rates associated with lower eGFR was steeper. In the same study, the association between eGFR and end-stage kidney disease (ESKD, defined as the initiation of kidney replacement treatment or death coded as due to kidney disease other than acute kidney injury) did not vary with age on the hazard ratio or absolute rate scales. How do we interpret these findings? Does age modify the association between eGFR and mortality? Does this study provide evidence that considerations about age are irrelevant with respect to the association between rates of ESKD and levels of eGFR? The role of age in defining CKD and assessing its prognosis has been a matter of longstanding debate [4]. Some members of the kidney community have raised concerns that the current CKD definition based on a single eGFR threshold artificially inflates the size of the population with CKD by labeling many older adults who have an age-related decline in kidney function with a disease that they do not have [5]. Existing studies on how age may modify the association between eGFR and adverse outcomes have been interpreted to support opposite views of how eGFR should be used to define CKD [6], especially in the majority of adults who are 65 years old or older and have an eGFR between 45 and 59 mL/min/1.73 m2 with normal or mild albuminuria [7]. In this article, we first review epidemiological measures of outcome occurrence and association.
Peb mam li siv cov ntsiab cai no rau kev sib tham txog qhov tseeb thiab txheeb ze tus nqi lossis kev pheej hmoo ntawm lub raum tsis ua haujlwm (nrog lossis tsis muaj kev kho raum hloov) thiab kev tuag thoob plaws pawg ntawm eGFR thiab hnub nyoog.
EPIDEMIOLOGICAL MEASURES FREQUENCY THIAB ASSOCIATION
Kev ntsuas zaus
Thawj kauj ruam hauv kev kwv yees qhov kev sib koom ntawm qhov tshwm sim thiab qhov tshwm sim yog ntsuas seb qhov tshwm sim tshwm sim ntau npaum li cas ntawm qhov raug. Qhov xwm txheej thiab qhov tshwm sim feem ntau yog cov txiaj ntsig zoo tshaj plaws hauv kev tshawb fawb txog kev kis kab mob. Qhov xwm txheej ntsuas qhov tshwm sim ntawm cov xwm txheej tshiab ntawm qhov tshwm sim hauv ib chav tsev ntawm tus neeg-lub sijhawm. Tus nqi no kuj tau hu ua tus neeg-lub sij hawm tus nqi, qhov xwm txheej ceev, quab yuam ntawm morbidity, txaus ntshai tus nqi thiab kab mob siv. Peb lo lus tom kawg no feem ntau siv los hais txog qhov txwv qhov xwm txheej tshwm sim raws li chav tsev ntawm lub sijhawm zero [8]. Ntawm qhov kev ceeb toom, lub sijhawm suav nrog tus lej ntawm qhov xwm txheej, uas ua rau qhov xwm txheej ntsuas qhov "ceev" ntawm cov txheej txheem kab mob.
Qhov feem pua ntawm qhov xwm txheej (lossis qhov xwm txheej sib sau) ntsuas qhov feem pua ntawm cov pej xeem muaj kev pheej hmoo uas tsim cov txiaj ntsig ntawm kev txaus siab nyob rau lub sijhawm teev tseg thiab yog qhov kwv yees ncaj qha ntawm kev pheej hmoo [8]. Qhov feem pua ntawm qhov xwm txheej tsis muaj qhov tsis muaj thiab lub sijhawm tsis suav nrog tus lej ntawm feem. Yog li ntawd, kev pheej hmoo yog ib qho kev ntsuas ntawm tag nrho cov kev ncua deb uas cov txheej txheem tshwm sim tau mus dhau lub sij hawm luv luv. Txij li thaum qhov tshwm sim feem ntau nce monotonically nyob rau lub sijhawm, ib qho kev siv sijhawm tshwj xeeb yuav tsum tau txuas nrog rau qhov kwv yees ntawm qhov xwm txheej.
Rau uncensored binary tshwm sim,
Rau censored event-history (survival) data, common nonparametric txoj kev kwv yees cov xwm txheej tshwm sim muaj xws li Kaplan-Meier (thaum tsis muaj cov xwm txheej sib tw) thiab Aalen-Johansen (thaum muaj cov xwm txheej sib tw) kwv yees. siv nyob rau hauv cov ntaub ntawv kho mob, txawm hais tias qhov kev ntsuas qhov tshwm sim hauv kev kawm yuav yog qhov xwm txheej (ceev), uas feem ntau tsis meej pem nrog kev pheej hmoo (nruab deb mus ncig hauv ib lub sijhawm). Lub tswv yim ntawm kev pheej hmoo siv rau cov tib neeg thiab pab pawg hauv cov pej xeem. Ib qho kev pheej hmoo ntawm tus kheej yog hais txog qhov txheeb ze ntawm qhov xwm txheej hauv ib pawg ntawm cov tib neeg (cov qauv kev tshawb fawb) uas muaj cov yam ntxwv zoo sib xws rau cov pej xeem lub hom phiaj [8]. Piv txwv li, yog hais tias tus neeg mob tau hais tias nws muaj 80% kev pheej hmoo ntawm ib qho kev tshwm sim ntawm 5- xyoo kwv yees lub qab ntug (kev pheej hmoo tshaj 5 xyoo), nws txhais tau tias yog tias muaj 100 tus neeg mob zoo li lawv, 80 yuav ntsib qhov xwm txheej los ntawm 5 xyoo.
Hauv qhov chaw kho mob, kev pheej hmoo yog qhov txiaj ntsig zoo dua qhov tshwm sim ntsuas dua li tus nqi. Tus neeg mob xav paub txog qhov txaus ntshai ntawm kev tshwm sim los ntawm qee lub sijhawm yav tom ntej (qhov tsis yooj yim khaws lossis nyob deb ntawm lub sijhawm ntawd) es tsis yog qhov ceev ntawm cov txheej txheem kab mob. Piv txwv li, nws yooj yim dua rau tus neeg mob kom nkag siab lub ntsiab lus ntawm 10% kev pheej hmoo ntawm kev mob plawv hauv 5 xyoo dua li tus nqi ntawm 2 lub plawv mob rau 100 tus neeg-xyoo, uas yuav ua rau muaj kev pheej hmoo ntawm 5 xyoo yog tias qhov no. tus nqi tseem nyob tas li. Hloov chaw, tus nqi, zoo li qhov nrawm, feem ntau sib txawv raws lub sijhawm thiab yog li tsuas yog muab cov ntaub ntawv tsis ncaj qha txog kev mus ncig hauv ib lub sijhawm. Tsis tas li ntawd, nyob rau hauv kev sib tw qhov kev pheej hmoo, txhua qhov kev pheej hmoo tsis yog nyob ntawm ib tus nqi txaus ntshai thiab ib qho kev kwv yees tawm (kev sib xyaw ntawm tus kheej tus yam ntxwv thiab tus qauv coefficients) tab sis ntawm txhua qhov kev kwv yees kev phom sij thiab kev kwv yees kab. Cov kev pheej hmoo suav tias lwm qhov kev pheej hmoo sib tw tsis muaj nyob yog overestimated [9, 10].
Kev ntsuas kev sib koom tes
Lub koom haum (lossis cov txiaj ntsig, thaum tsis muaj kev tsis ncaj ncees thiab tsis meej pem) ntawm qhov xwm txheej lossis qhov tshwm sim ntawm qhov tshwm sim yog qhov kev hloov pauv ntawm qhov txiaj ntsig ntsuas (tus nqi lossis kev pheej hmoo) raws li qib ntawm qhov cuam tshuam lossis raug hloov pauv. Kev ntsuas ntawm kev sib koom ua ke tuaj yeem yog qhov sib txawv ntawm qhov sib txawv, qhov sib txawv ntawm qhov sib piv, qhov phom sij txaus ntshai, qhov sib txawv ntawm qhov kev pheej hmoo lossis kev pheej hmoo (Table 1). Muab cov nqi txheeb ze nkaus xwb (lossis txaus ntshai) tuaj yeem ua rau cov ntaub ntawv tsis raug, vim qhov piv ntawm ob tus nqi (kev pheej hmoo) yuav tsis muaj txiaj ntsig zoo yog tias tus nqi siv (kev pheej hmoo) tsawg. Piv txwv li, ib tus neeg caij tsheb kauj vab tuaj yeem caij tsheb kauj vab ob zaug nrawm dua li lwm tus neeg caij tsheb kauj vab, tab sis lawv ob leeg yuav tau mus deb heev yog tias ob lub nrawm yog 0.5 thiab 1 km ib teev thiab tag nrho cov kev taug kev yog 1{{ 1 0}}0 km. Yog tias qhov kev ncua deb ntawm lub ntsiab lus los npog hauv 1 h yog 10 tawm ntawm tag nrho 100 km (xws li 1- xyoo muaj txiaj ntsig qhov pib ntawm 10%), ob tus neeg caij tsheb kauj vab yuav ua tiav tsuas yog 0.5-1/100 ntawm qhov kev ncua deb hauv 1 h (lawv qhov kev pheej hmoo ntawm 0.5% -1% ntawm 1 xyoo yog deb tshaj qhov pib ntawm qhov muaj txiaj ntsig zoo). Txawm hais tias tus txheeb ze ceev ntawm 2 yog qhov zoo siab, thaum qhov sib piv ceev tau nthuav tawm nrog cov feem ntawm qhov kev ncua deb mus rau ib chav tsev ntawm lub sij hawm los ntawm txhua tus neeg caij tsheb kauj vab txheeb ze rau tag nrho cov lus peb kev hloov pauv. Cov neeg caij tsheb kauj vab taug kev ntawm qhov sib txawv ntawm qhov sib txawv ntawm qhov sib txawv ntawm lawv qhov nrawm tsis cuam tshuam nrog rau tag nrho qhov kev ncua deb los npog (Daim duab 1).
Clinical epidemiologists tau npaj cov kev ntsuas ntawm kev soj ntsuam qhov cuam tshuam xws li tus lej xav tau los kho (uas yog qhov hloov pauv ntawm qhov sib txawv ntawm qhov kev pheej hmoo tsis txaus ntseeg) [11] los qhia txog qhov tseem ceeb ntawm kev muab kev ntsuas meej ntawm tus kab mob tshwm sim nrog cov txiaj ntsig txheeb ze thaum nthuav tawm cov txiaj ntsig ntawm kev soj ntsuam kev sim [12]. Txawm li cas los xij, hauv cov kev tshawb fawb soj ntsuam kev sib kis feem ntau, qhov twg tib lub hauv paus ntsiab lus siv, feem ntau tsuas yog ntsuas ntawm cov koom haum tau nthuav tawm (cov txheeb ze txaus ntshai lossis tus nqi) [13]. Thaum cov kev ntsuas meej tau nthuav tawm, cov kev pheej hmoo tsis tshua muaj.
Hnub nyoog thiab kev koom tes ntawm eGFR thiab cov txiaj ntsig kev kho mob tsis zoo
Qhov tshwm sim ntawm qhov tshwm sim tsis zoo tshwm sim feem ntau nce nrog cov hnub nyoog nce qib. Nws yog qhov paub zoo tias GFR poob qis nrog cov hnub nyoog laus [14]. Feem ntau cov kev tshawb fawb txog kev sib kis ntawm kev sib koom ua ke ntawm lub raum kev ua haujlwm thiab cov txiaj ntsig tsis zoo nyob ntawm kwv yees GFR es tsis yog ntsuas GFR. Nws yog ib qho tseem ceeb uas yuav tsum nco ntsoov tias hnub nyoog yog ib qho ntawm cov tswv yim sib txawv siv los kwv yees GFR thiab tseem suav nrog eGFR hauv cov txiaj ntsig ua qauv. Qhov cuam tshuam ntawm kev coj ua tsis meej [15].
Txawm hais tias kev xav txog ntau yam ntawm cov txiaj ntsig kev kho mob tseem ceeb, cov kev tshawb fawb uas twb muaj lawm los tshuaj xyuas cov koom haum ntawm eGFR thiab cov txiaj ntsig tsis zoo raws li lub hnub nyoog tau tsom mus rau qhov tshwm sim ntawm txhua qhov kev tuag thiab qhov tshwm sim loj tshaj plaws ntawm lub raum tsis ua haujlwm, feem ntau txhais tau tias yog pib ntawm kev kho raum hloov [3, 7, 16, 17]. Qhov kev txhais ntawm lub raum tsis ua haujlwm no yuav ua yuam kev feem ntau ntawm cov neeg laus uas tau xaiv tsis kho lub raum tsis ua haujlwm nrog raum hloov kho [18].
Daim duab 1: Ib qho piv txwv ntawm tus txheeb ze tus nqi thiab qhov txaus ntshai. Cov neeg caij tsheb kauj vab taug kev sib txawv ntawm qhov nrawm (qhov sib piv ceev ntawm 2), tab sis qhov kev ncua deb lawv tau mus dhau 1 h (1 thiab 0.5 km) tsis cuam tshuam rau ob qho tib si rau tag nrho cov kev ncua deb ntawm 100 km.
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