可估計有風險患者之腎衰竭風險的工具


  【24drs.com】研究者在發表於1月12日JAMA期刊的文章中報告指出,運用兩種腎衰竭風險方程式的線上工具,看來可以準確預測不同地區、不同族群之慢性腎病患者(CKD)在2-5年時的腎衰竭風險。
  
  慢性腎臟病預後聯盟領導人、Bloomberg學院流行病學George W. Comstock名譽教授Josef Coresh博士在新聞稿中表示,這個工具讓醫師們可以坐下來向他們的患者解釋,患者最近發生腎衰竭的機率有多少。
  
  雖然這個工具可以輔助管理患者的疾病,並讓他們做好最壞的打算,但是,有更多患者可以發現令人放心的結果。你可以讓大部份憂心忡忡者安心,因為他們的風險實際上是相當低的,大部份患者將不需要透析。
  
  之前的報導指出,使用4種和8種變項方程式建立的工具,最初是在加拿大、安大略使用3,449名第3-5期CKD患者的資料所發展,在加拿大、英屬哥倫比亞的對照CKD患者驗證。研究作者們解釋,4種變項的方程式需要年齡、性別、估計腎絲球過濾速率、尿液白蛋白/肌酸酐比值;8種變項的方程式還需要鈣、磷酸鹽、碳酸氫鹽和白蛋白,當需要的精度更高時,它比較有用。
  
  這篇研究中,加拿大Winnipeg Manitoba大學Seven Oaks綜合醫院內科部的Navdeep Tangri博士等人,在一篇協同統合分析中評估了一種工具,研究對象包括來自31個世代(16個在北美、15個來自亞洲、歐洲與澳洲)的721,357名CKD第3-5期的患者,平均追蹤4.2年。
  
  藉由估計與合併世代特定風險比、使用原始方程式的風險因素,研究者建立了一個新的彙整的腎衰竭風險方程式。
  
  他們報告指出,總體而言,匯集4種和8種變項的方程式,獲得了與原始方程式類似的鑑別作用,但可以更精準地預測2年和5年時的腎衰竭機率。
  
  作者們解釋,對於這兩種方程式的必要組成因素都有的世代而言,8種變項之風險方程式的鑑別可能略優於4種變項的方程式,對於所有有興趣(加以分析)的分組類別而言,不論是使用原始方程式或彙整的風險方程式,都是如此。
  
  他們指出,大部份的北美世代不需要校正;不過,對於非北美世代進行區域校正因素可改善校準,讓風險方程式在不同風險基準的各個國家也可以有臨床用途。
  
  Tangri博士等人寫道,使用的4種變項的方程式與「腎臟病改善全球結果(Kidney Disease Improving Global Outcomes[KDIGO]」的指引一致,建議整合風險預測以評估和處置CKD,也有強力證據顯示[估計腎絲球過濾速率]和白蛋白尿在預測預後時的重要性。此外,它也可以很容易地應用在電子病歷和實驗室資訊系統。
  
  作者們聲明指出,8種變項的方程式觀察到的逐步改善比原始研究小,但是,對於資料可用於這兩種方程式的患者來說,仍是有意義的。
  
  這些結果認為,4種變項的風險方程式或許可以更廣泛地運用,但是,如果獲得更多變項,則應使用8種變項的方程式,以提高所需要的精準度。
  
  資料來源:http://www.24drs.com/
  
  Native link:Tool Estimates Likelihood of Kidney Failure in At-Risk Patients

Tool Estimates Likelihood of Kidney Failure in At-Risk Patients

By Diana Phillips
Medscape Medical News

An online tool that uses two kidney failure risk equations appears to accurately predict the probability of kidney failure at 2 and 5 years in individuals with chronic kidney disease (CKD) across a wide range of geographic regions and patient populations, researchers report in an article published in the January 12 issue of JAMA.

"This tool allows doctors to sit down with their patients and explain how likely it is that their kidneys will fail in the near future," Josef Coresh, MD, PhD, the George W. Comstock Professor of Epidemiology at the Bloomberg School, and head of the Chronic Kidney Disease Prognosis Consortium, which conducted the study, said in a news release.

"While the tool can aid in management of a patient's disease and prepare them for the worst, many more patients will find the results reassuring. You can reassure a lot of worried people with the fact that their risk is actually very low. The vast majority of patients will not need dialysis," he added.

As previously reported by Medscape Medical News, the tool, which uses four- and eight-variable equations, was initially developed using 3449 patients with stages 3 to 5 CKD in Ontario, Canada, and validated in referred patients with CKD in British Columbia, Canada. The four-variable equation requires age, sex, estimated glomerular filtration rate, and urinary albumin-to-creatinine ratio, whereas the eight-variable equation also requires calcium, phosphate, bicarbonate, and albumin, making it useful when more precision is desired, the study authors explain.

In the current study, Navdeep Tangri, MD, PhD, from the Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Canada, and colleagues evaluated the tool in a collaborative meta-analysis comprising 721,357 participants with CKD stages 3 to 5 from a total of 31 cohorts (16 based in North American and 15 from Asia, Europe, and Australasia) with an average follow-up of 4.2 years.

The researchers formed new pooled kidney failure risk equations by estimating and combining cohort-specific hazard ratios, using risk factors from the original equations.

"In general, the pooled 4- and 8-variable equations resulted in similar discrimination to the original equations," which were excellent for the 2- and 5-year predicted probability of kidney failure, they report.

"Discrimination of the 8-variable risk equation was slightly better than the 4-variable equation in cohorts that had the necessary components for both equations," the authors explain, noting this to be true using either the original or the pooled risk equations and in nearly all subgroups of interest.

Recalibration was not needed in most North American cohorts; however, a regional calibration factor in non-North American cohorts improved calibration, making the risk equations clinically useful in countries with different levels of baseline risk, they add.

The use of the four-variable equation "is consistent with the Kidney Disease Improving Global Outcomes (KDIGO) guideline, which recommends integration of risk prediction in the evaluation and management of CKD and is in agreement with a strong body of evidence demonstrating the importance of [estimated glomerular filtration rate] and albuminuria in predicting prognosis," Dr Tangri and colleagues write. In addition, it can easily be implemented in electronic medical records and laboratory information systems.

The incremental improvement observed with the eight-variable risk equation "was smaller than in the original study but may be meaningful for patients for whom data for both equations is readily available," the authors state.

"These findings suggest that the 4-variable risk equation might be adopted more widely, but the 8-variable equation should be made available if the additional variables are obtained and increased precision is desired."

The tool is freely available at http://www.kidneyfailurerisk.com.

Dr Tangri reports financial relationships with Takeda Inc and Otsuka. Study coauthors also disclosed patent applications pending for glomerular filtration rate estimation and relationships with CKD-EPI, Amgen, Merck, Astra Zeneca, ZS Pharma, Hospira, NxStage, Relypsa, Bayer, Astellas, Pharmalink AB, Otsuka, Gilead Sciences, Abbott, NPS, sanofi-aventis, ZS Pharma, AbbVie, OPKO, Shire, Boehringer Ingelheim, and Janssen.

JAMA. 2016;315:164-174.

    
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