Yam Tseem Ceeb Rau Kev Loj Hlob Ntawm Kab Mob Raum Hniav: Kev Tshawb Fawb Hauv Cov Me Nyuam Prepubertal
Oct 18, 2023
3 | TSEEM CEEB
Ib puas thiab nees nkaum tsib tus menyuam tau suav nrog hauv txoj kev kawm. Cov yam ntxwv ntawm tus neeg mob tau qhia hauv Table 1 thiab sib txawv rau cov neeg mob uas muaj kab mob glomerular lossis non-glomerular. Feem ntau ntawm cov neeg mob (90, 72%) yog cov neeg African dub, thiab feem ntau muaj hnub nyoog qis dua 7 xyoo thaum lub sijhawm suav nrog. Yuav luag ob zaug ntau yam uas tsis yog-glomerular (81) raws li glomerular (44) mob tau kuaj pom. Cov menyuam yaus uas tsis muaj glomerular tsis meej yog cov hluas, feem ntau yog txiv neej, thiab lawv muaj feem yuav muaj kev loj hlob loj heev. Ntshav siab tau raug kho nrog ntau yam kev sib txuas ntawm CCB, beta-blockers thiab ACEis. Thaum nkag 40 tus neeg mob (32%) tau txais ACEi thiab thaum tawm 18 tus neeg mob (14%). Tsis muaj leej twg ntawm cov neeg mob tau mus txog qhov kev loj hlob ntawm pubertal thaum lub sijhawm kawm thiab tsuas yog ob peb tus tau mus txog Tanner theem 2 txoj kev loj hlob. Tsis muaj leej twg tau nce mus dhau theem 2, tsis hais hnub nyoog li cas. Cov neeg mob tau ua raws li lub sijhawm nruab nrab ntawm 3.1 (IQR=1.8–6) xyoo.
NYEM QHOV NO RAU CISTANCHE RAUGLOMERULAR OR NON-GLOMERULAR DISEASE
Cov ntaub ntawv tsis tiav tau txais rau acidosis (n 3) thiab proteinuria (n 4). (Table 1 thiab 2). Qhov no suav nrog 0.93% ntawm cov ntaub ntawv kho mob thiab biochemical.
Yuav luag ib feem peb (31%) ntawm cov neeg mob yog los ntawm cov cheeb tsam nyob deb nroog thiab 14% los ntawm cov neeg txom nyem nyob rau hauv nroog. Tsev neeg tsis muaj nyiaj tau los ruaj khov hauv 18% ntawm cov neeg mob. Feem ntau ntawm cov tsev neeg nyob ntawm cov nyiaj pab kev noj qab haus huv. Lub sijhawm taug kev mus rau lub tsev kho mob nephrology yog ntau tshaj 4 h rau 35% ntawm cov neeg mob. Tsuas yog 37% ntawm cov neeg mob raug coj mus rau lub tsev kho mob hauv kev thauj mus los ntiag tug. Cov xwm txheej no tau ua lub luag haujlwm rau qee qhov teeb meem ntawm kev taug qab thiab kev ua raws li kev kho mob.
Thaum lub sij hawm txiav tawm ntawm txoj kev tshawb no, 42 (34%) ntawm cov neeg mob tau nce mus rau CKD theem 5. Cov ntaub ntawv kho mob thiab cov chaw kuaj mob thiab lawv cov kev koom tes nrog kev nce mus rau CKD theem 5 tau piav qhia hauv Table 2. Qhov no qhia txog kev faib ua feem ntawm cov neeg mob. txhua qhov kev pheej hmoo uas ua rau lub raum tsis ua haujlwm. Kev soj ntsuam Univariate pom tias muaj proteinuria thiab kab mob glomerular yog qhov tseem ceeb, thiab theem 4 kab mob marginally, cuam tshuam nrog kev loj hlob. Ntawm qhov kev hloov kho kho qhov tshwm sim ntawm CKD, anemia, acidosis thiab kub siab tsis ncav cuag qhov tseem ceeb raws li kev pheej hmoo rau kev nce qib thaum proteinuria tau ua. Cov kab mob metabolic acidosis tau tshwm sim nyob rau hauv 13 ntawm 15 tus menyuam yaus uas tsis yog-glomerular kab mob uas tau mus txog qhov kawg, tab sis qhov no kuj ua tsis tiav qhov tseem ceeb (p .2). Ib qho kev soj ntsuam ntawm tus neeg mob pw ua ke tau qhia tias cov ntxhais tau mus txog qhov kawg ntawm kev txheeb xyuas sai dua cov tub.
Multivariate regression tsom xam pom proteinuria, CKD theem 4 thiab kab mob glomerular los ua ywj siab kwv yees ntawm kev loj hlob mus rau lub raum tsis ua haujlwm (Table 3).
Lub sijhawm nruab nrab ntawm kev muaj sia nyob ntawm lub raum ua haujlwm rau txhua tus neeg mob yog 10.8 xyoo. Lub raum ua haujlwm lub sijhawm muaj sia nyob thiab qhov xwm txheej txaus ntshai rau txhua qhov kev pheej hmoo muaj nyob rau hauv Table 4. Qhov no qhia txog lub sijhawm muaj sia nyob nruab nrab rau txhua yam kev pheej hmoo. Hauv qhov kev tshuaj ntsuam no, kab mob glomerular, proteinuria thiab poj niam pw ua ke yog qhov tseem ceeb, thiab ntshav qab zib yog qhov tsis zoo, kwv yees lub sijhawm luv rau lub raum. Qhov no tau piav qhia txog peb yam los ntawm Kaplan-Meier nkhaus hauv daim duab 1. Acidosis thiab kub siab tsis cuam tshuam nrog lub sijhawm rau lub raum tsis ua haujlwm. Multivariate regression pom proteinuria, CKD theem 4 thiab kab mob glomerular los ua tus kws tshaj lij ntawm lub raum ua tsis tiav. Poj niam pw ua ke yog qhov kev twv ua ntej (Table 5).
Tus nqi ntawm kev poob qis hauv GFR ntawm txhua tus neeg mob thaum lub sij hawm tag nrho cov kev soj ntsuam tau suav ua ib xyoos ib zaug rau cov kab mob glomerular thiab nonlomerular. Kev poob qis ntawm ntau dua 5 mL / min / 1.73 m2 / xyoo tshwm sim hauv 82% ntawm cov neeg mob glomerular piv nrog 5% nrog cov kab mob uas tsis yog glomerular. Plaub caug yim (38%) ntawm cov neeg mob tau poob qis hauv GFR ntawm<1 mL/min/1.73m2 /year over the study period, mostly children with non-glomerular disorders. The median GFR decline was more pronounced in patients with glomerular disorders (16.8 [IQR = 9.5–26.2]) than in patients with non-glomerular disorders (1.32 [IQR = 3.43-3.86] mL/min/1.73 m2 /year). The excessive decline in patients with glomerular disease may, however, be due to skewed distribution, with a data skewness coefficient of 1.27.
4|Kev sib tham
Nyob rau hauv txoj kev tshawb no, kev koom tes ntawm cov kev sib txawv uas cuam tshuam txog kev loj hlob ntawm CKD tau tshawb xyuas hauv cov menyuam yaus prepubertal vim tias qhov kev xav tias qhov sib txawv yuav cuam tshuam los ntawm kev cuam tshuam ntawm lub cev ntawm kev puberty. Deterioration ntawm lub raum ua haujlwm thaum hluas yog ib qho tshwm sim uas paub txog cov kws kho mob nephrologists. Cov laj thawj tsis paub meej thiab tsis tau kawm zoo.13,14 Qhov kev piav qhia ntawm qhov kev loj hlob yog qhov kev ua haujlwm ntxiv los ntawm kev ua kom lub cev muaj zog ntawm cov neeg laus, suav nrog cov leeg nqaij, ntawm qhov tsawg ntawm cov nephrons ua haujlwm ntxiv. Rau cov laj thawj no, nws tau xav tias muaj txiaj ntsig los tshuaj xyuas cov xwm txheej cuam tshuam nrog CKD kev nce qib tsis cuam tshuam rau kev cuam tshuam loj ntawm kev puberty.
FIGURE 1 Kaplan-Meier nkhaus ntawm lub raum ciaj sia nyob rau hauv piv rau glomerular thiab non-glomerular kab mob hauv A, qhia cov teebmeem ntawm proteinuria hauv B thiab CKD theem 4 hauv C, thiab rau txhua tus neeg mob hauv D
Kev tshawb fawb ntawm CKD kev nce qib hauv cov menyuam yaus tsis sib xws suav nrog cov tub ntxhais hluas thiab cov tub ntxhais hluas tom qab kev kawm, thaum tsis muaj ib tus menyuam yaus hauv txoj kev tshawb no tau mus txog hnub nyoog laus thaum lub sijhawm rov qab los. Qee qhov kev kwv yees ntawm kev nce qib hauv txoj kev tshawb fawb no tau zoo ib yam li lwm cov kev tshawb fawb txog menyuam yaus. Proteinuria thiab kab mob glomerular tau raug tshaj tawm tsis tu ncua los ua qhov kev kwv yees muaj zog hauv txhua qhov kev tshawb fawb, 18 thiab qhov no tau lees paub hauv cov menyuam yaus prepubertal kawm ntawm no. Qee qhov kev hloov pauv hloov pauv tau tshaj tawm tias tseem ceeb hauv lwm cov kev tshawb fawb tau, txawm li cas los xij, tsis nyob hauv peb cov kev kawm. Ntshav siab tau raug tshaj tawm tias yog ib qho kev kwv yees tseem ceeb ntawm kev nce qib hauv ntau qhov kev tshawb fawb menyuam yaus. Qhov kev sim ESCAPE, uas suav nrog cov menyuam yaus hnub nyoog qis dua 18 xyoo, pom tau tias kev tswj ntshav siab nruj tau txais txiaj ntsig hauv kev txo qis kev loj hlob ntawm CKD hauv cov menyuam yaus.9 Daim ntawv tshaj tawm los ntawm Warady li al. kuj tau qhia qhov no: ntshav siab tau cuam tshuam nrog 67% txo lub sijhawm rau lub raum ua haujlwm kawg.8 Txawm li cas los xij, qhov kev tshawb fawb no suav nrog cov menyuam yaus txog 16 xyoo, nrog rau lub hnub nyoog nruab nrab ntawm 11 xyoo hauv cov menyuam yaus uas tsis muaj kab mob glomerular, thiab 15 xyoo nrog kab mob glomerular. Hauv tsab ntawv ceeb toom los ntawm North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) sau npe, cov menyuam yaus uas muaj ntshav siab tau nce mus rau CKD theem 5 ob xyoos sai dua cov menyuam yaus uas tsis muaj ntshav siab.10 Hauv cov kev sim no, cov menyuam yaus prepubertal tsis tau categorized lossis soj ntsuam nyias. Hauv txoj kev tshawb fawb tam sim no, 69 tus menyuam yaus (55%) tau mob siab rau ntawm kev nthuav qhia, tab sis qhov no tsis cuam tshuam nrog kev loj hlob ntawm CKD mus rau qhov kawg.
Anemia yog ib qho tshwm sim ntawm CKD. Nws tau raug tshaj tawm nyob rau hauv ntau cov kev tshawb fawb los cuam tshuam nrog kev nce qib.7,8,18 Kev tswj ntshav qab zib hauv cov menyuam yaus uas tsis tau lim ntshav CKD yog qhov nyuaj thiab tsawg dua qhov txaus siab. Txawm li cas los xij, tsis muaj kev hloov pauv me ntsis ntawm qhov tshwm sim ntawm anemia thaum lub sijhawm kawm ntawm qhov kev tshawb fawb no. Rau caum-ob (49.6%) ntawm peb cov neeg mob tau anemic thaum nkag thiab 59 (47.2%) ntawm kev txiav. Anae mia tsis cuam tshuam nrog kev loj hlob mus rau qhov kawg.
Kev nthuav qhia ntawm cov neeg mob uas muaj tus kab mob siab heev tau kwv yees tau cuam tshuam nrog kev loj hlob. Qhov no tau tshwm sim nyob rau hauv lwm yam kev tshawb fawb.1,7,10,14 Nws tau corroborated nyob rau hauv txoj kev tshawb no, qhov twg cov neeg mob nrog theem 4 CKD nyob rau hauv nkag tau muaj ib tug sib txawv ratio ntawm 6.95 mus txog qhov kawg.
Proteinuria tau ua pov thawj tsis tu ncua los ua ib qho kev kwv yees tseem ceeb ntawm CKD kev nce qib hauv cov neeg laus nrog rau kev tshawb fawb txog menyuam yaus, 11, 12, 18, tshwj xeeb tshaj yog rau cov neeg mob glomerular disorders uas tseem muaj kev pheej hmoo ntawm kev mob ntshav siab. Los ntawm CKiD cohort, Wong et al tau tshaj tawm tias cov neeg mob glomerular disorders ua rau CKD muaj UPCR qib uas nyob nruab nrab 140% siab dua li cov neeg mob uas tsis yog glomerular etiology.11 Cov laj thawj ntawm CKD tuaj yeem cuam tshuam nrog ntau qib ntawm proteinuria. thiab tus nqi ntawm kev nce qib. Kev loj hlob sai tshwm sim feem ntau hauv pawg tub ntxhais hluas uas tseem muaj qhov tshwm sim ntau dua ntawm glomerulonephritis. Proteinuria thiab glomerular disorders raws li kev kwv yees ntawm CKD kev loj hlob yog corroborated nyob rau hauv txoj kev tshawb no ntawm cov me nyuam prepubertal. Ob yam no yog li ntawd zoo li cuam tshuam rau kev loj hlob ntawm lub raum dys ua haujlwm ntawm nws tus kheej ntawm cov teebmeem ntawm kev puberty.
Metabolic acidosis tau tshaj tawm tias muaj feem cuam tshuam nrog CKD kev nce qib.8,19 Harambat thiab al cais acidosis rau hauv peb theem hauv pawg menyuam loj. Bicarbonate qib ntawm<18 mmol/L were associated with a significantly greater risk of progression than levels of <22 mmol/L.20 The study population subjects had a median age of 12.3 years, unlike the prepubertal children in the current study.
Kev sib piv ntawm lub raum ciaj sia nyob rau hauv cov tub hluas thiab cov ntxhais tau ua vim qhov pom tau tias qeeb qeeb ntawm CKD hauv cov poj niam.21 Hauv kev tshawb fawb CKiD ntawm cov menyuam yaus txhua lub hnub nyoog, CKD tau nce nrawm dua hauv cov tub hluas dua li cov ntxhais.8 Hauv peb pawg, txawm li cas los xij , cov ntxhais tau mus txog CKD theem 5 ntau dua li cov tub. Qhov no qhia tau hais tias kev hloov pauv ntawm lub cev thaum lub sij hawm thiab tom qab kev laus muaj feem cuam tshuam rau kev loj hlob ntawm CKD hauv cov tub thiab ntxhais sib txawv.
Rau qhov zoo tshaj plaws ntawm peb txoj kev paub, tsis muaj kev kawm txog kev loj hlob ntawm CKD hauv cov menyuam yaus prepubertal nkaus xwb tau luam tawm. Qee qhov kev tshawb fawb tau hais txog qhov kev loj hlob ntawm cov menyuam yaus no.13,14 Mitsnefes li al piv rau qee pawg hnub nyoog ntawm cov menyuam yaus uas muaj CKD thiab pom tias cov menyuam hnub nyoog 6-12 xyoo thiab 13-17 xyoo tau nce zuj zus sai dua li cov hnub nyoog 2-5. xyoo.10 Ib tsab ntawv ceeb toom los ntawm NAPRTCS pom tias cov me nyuam hnub nyoog 2-5 xyoos thiab cov me nyuam hnub nyoog 6-12 xyoo muaj kev phom sij tsawg dua 1 rau kev loj hlob ntawm CKD.7 Cov txiaj ntsig no qhia tias CKD hauv cov me nyuam yaus loj hlob qeeb dua. hauv cov menyuam yaus hnub nyoog qis dua thiab laus dua. Txawm li cas los xij, cov qauv ntawm txoj kev tshawb fawb tam sim no txawv rau cov uas tau hais nyob rau hauv uas peb tsuas yog nkag mus rau cov menyuam yaus prepubertal thiab kev txheeb xyuas txheeb cais tau tsom mus rau pab pawg no ib leeg. Nws yuav zoo li tias qee qhov kev pheej hmoo rau kev loj hlob ntawm CKD tau tshaj tawm hauv cov kev tshawb fawb suav nrog cov menyuam yaus, tsis muaj nyob hauv cov menyuam yaus prepubertal.
Qhov tsis muaj ntshav siab thiab ntshav ntshav ua rau muaj kev pheej hmoo rau kev nce mus rau qhov kawg hauv peb cov kev kawm yog qhov xav tsis thoob. Tej zaum yuav muaj cov lus piav qhia txog lub cev xws li hauv cov hlab ntsha thiab erythropoiesis ntawm lub hnub nyoog no. Tsis tas li ntawd, cov menyuam yaus tseem hluas thiab yog li raug cuam tshuam los ntawm CKD rau lub sijhawm luv. Qhov ua tau ntev ntev ntawm cov hlab plawv ntawm cov hlab plawv thiab ntshav siab tseem tsis tau tsim
Ntawm cov kev hloov pauv uas cuam tshuam rau kev loj hlob ntawm CKD hauv txoj kev tshawb no, glomerular disorders thiab kev nthuav qhia nrog cov kab mob siab heev yog qhov hloov tsis tau. Proteinuria, uas hloov tau, tau kho nrog ACEi. Txawm hais tias cov txiaj ntsig ntawm ACEis ntawm cov proteinuria tshwj xeeb hauv cov menyuam yaus African tsis paub, txawm li cas los xij, proteinuria tseem yog ib qho kev kwv yees tseem ceeb ntawm txoj kev kawm no. Kev lees paub ntawm qhov kev hloov pauv no raws li qhov muaj feem cuam tshuam rau kev loj hlob tuaj yeem yog vim qhov txiaj ntsig zoo ntawm ACEis ntawm proteinuria tuaj yeem yog evanescent.22
Txoj kev tshawb no muaj kev txwv. Cov menyuam yaus tsis tau ua raws li kev laus laus los saib xyuas cov teebmeem ntawm kev loj hlob ntawm CKD. Txoj kev tshawb no kuj tsis suav nrog ib pab pawg sib piv ntawm cov menyuam yaus tom qab pubertal.
Raws li nrog tag nrho cov ntaub ntawv tshawb fawb qee cov ntaub ntawv tau ploj lawm, txawm hais tias qhov no tsawg kawg hauv txoj kev tshawb no (<1%). A decided strength of this study is that all patient care and data recording were under the direct care of two pediatric nephrologists at all times.
Txoj kev tshawb no tau ua nyob rau hauv ib lub teb chaws tsim thiab yog li ntawd qee qhov kev sib tw logistic tau ntsib. Vim tias muaj kev mus ncig zoo heev, cov neeg mob qee zaum tsis tuaj yeem teem sijhawm thiab cov zis tso zis tsis yog ib txwm los ntawm kev sau thaum sawv ntxov. Cov tshuaj uas tau sau ua ntej, lub sijhawm, tsis muaj. Cov xwm txheej no tuaj yeem ua rau muaj kev nce qib ntawm CKD hauv pawg neeg no.
Txoj kev tshawb no tau soj ntsuam tsuas yog qhov sib txawv uas muaj nyob rau lub sijhawm ntawm kev nrhiav neeg ua haujlwm thiab yog li tsis xav txog cov txiaj ntsig ntawm kev tswj xyuas tom ntej xws li kev kub siab. Peb xav tias txawm li cas los xij tias peb qhov kev tshawb pom muaj peev xwm ua tau vim tias cov neeg mob tau raug tswj hwm raws li KDIGO cov lus qhia. Ob peb ntawm cov kev tshawb fawb tau siv cov qauv zoo sib xws.7,8,16
Raws li nrog ntau cov kev tshawb fawb soj ntsuam ntawm qhov xwm txheej no, peb cov neeg raug kev txom nyem los ntawm kev siv kwv yees GFR raws li lub txaj txaj Schwartz nkaus xwb, tsis yog CKidU25. Qhov no tau ua tiav los ntawm kev txaus siab ntawm kev sib koom ua ke thiab vim tias Cystatin C tsis muaj nyob hauv lub xeev cov chaw sim hauv South Africa. Tsis tas li ntawd, kev ntsuas ntshav creatinine yuav tsis sib haum ntawm cov chaw kuaj mob. Txawm li cas los xij, qee qhov kev tsis sib xws yog xa mus rau hauv txoj kev tshawb fawb no vim tsuas yog ob lub chaw soj nstuam yog lub luag haujlwm rau kev soj ntsuam hauv chav kuaj.
5|TEEB MEEM
Kev loj hlob ntawm CKD rau lub raum tsis ua haujlwm yuav txawv ntawm cov neeg laus, cov hluas thiab cov menyuam yaus. Txoj kev tshawb no tau soj ntsuam cov kev pheej hmoo rau kev loj hlob ntawm cov me nyuam prepubertal. Lub xub ntiag ntawm cov kev hloov pauv hloov tau ntawm CKD kev nce qib xws li ntshav siab, ntshav ntshav thiab acidosis ntawm qhov kev ntsuam xyuas thawj zaug, tsis tau kwv yees txog kev nce mus rau ESKD hauv cov menyuam yaus uas tseem tsis tau mus txog hnub nyoog laus. Tsuas yog cov kab mob glomerular, proteinuria thiab theem 4 CKD yog tus kws tshaj lij nyob hauv pawg neeg no. Qhov tsis muaj qhov cuam tshuam ntawm kev hloov pauv ntawm qhov kev loj hlob ntawm CKD hauv txoj kev tshawb no qhia tias kev tshawb fawb ntau ntxiv ntawm cov txheej txheem pathological hauv cov menyuam yaus prepubertal tuaj yeem nthuav tawm cov hom phiaj ntau rau kev kho mob.
REFERENCES
1. Furth SL, Abraham AG. Jerry-Fluker et al. Metabolic abnormalities, kab mob plawv, thiab GFR poob rau cov me nyuam uas muaj kab mob raum. Clin J Am Soc Nephrol. 2011; 6(9):{5}}. doi: 10.2215/CJN.07100810
2. Collins AJ, Foley RN, Herzog C, et al. United States renal data system 2008 txhua xyoo cov ntaub ntawv qhia. Am J Raum Dis. 2008;53(1 suppl):S1-S374. doi: 10.1053/j.ajkd.2008.10.005
3. Warady BA, Chadha V. Mob raum mob rau cov menyuam yaus: qhov kev xav thoob ntiaj teb. Pediatr Nephrol. 2007; 22(12):{4}}. doi: 10.1007/s 00467-006-0410-1
4. Ashuntantang G, Osafo C, Olowu WA, et al. Cov txiaj ntsig ntawm cov neeg laus thiab cov menyuam yaus uas muaj kab mob raum kawg uas yuav tsum tau lim ntshav hauv sub-Saharan Africa: kev tshuaj xyuas zoo. Lancet Glob Health. 2017;5(4): e408-e417. doi:10.1016/S2214-109X(17){12}}
5. Ardissino G, Daccò V, Testa S, et al. Kev kis kab mob ntawm lub raum tsis ua haujlwm rau cov menyuam yaus: cov ntaub ntawv los ntawm ItalKid project. Pediatrics. 2003; 111(4 Pt 1):e{5}}e387. doi: 10.1542/peb.111.4.e382
6. Schaefer B, Wühl E. Daim ntawv qhia kev kawm: kev loj hlob ntawm cov kab mob raum thiab cov tswv yim tiv thaiv. Eur J Pediatr. 2012; 171(11):1579- 1588. doi: 10.1007/s00431-012-1814-5
7. Staples AO, Greenbaum LA, Smith JM, et al. Kev sib koom ua ke ntawm cov tshuaj muaj feem cuam tshuam thiab kev loj hlob ntawm cov kab mob raum ntev hauv cov menyuam yaus. Clin J Am Soc Nephrol. 2010; 5(12):{4}}. doi: 10.2215/CJN. 07851109 ib
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