蛋白尿無法幫助預測子癲前症之母親或胎兒的結果


  March 27, 2009 — 根據3月24日BMC Medicine期刊線上版的系統性回顧研究結果,估計子癲前症(preeclampsia)孕婦的蛋白尿值,對於預測母親或胎兒的結果並無實際臨床助益。
  
  英國布萊根婦女醫院的Shakila Thangaratinam等人寫道,蛋白尿是臨床診斷子癲前症的一個重要準則。蛋白尿值增加被視為與母親及胎兒結果不佳有關。我們的目標在於藉由系統性量化回顧檢測準確度的研究,確認子癲前症婦女之蛋白尿值預測母親和胎兒併發症結果的準確度。
  
  為了確認相關文獻,研究者於MEDLINE(1951-2007)、EMBASE (1980-2007)、Cochrane Library(2007)以及MEDION等資料庫進行搜尋、未設定語言限制。他們也以人工搜尋特定期刊與引述等檢索文章的參考文獻。由兩位回顧者獨立選擇有關子癲前症者以蛋白尿預測母親和胎兒併發症之準確度研究。以母親和胎兒併發症作為參考標準,畫出一個2 x 2的表格,涵蓋研究特徵、品質與準確度的資料。
  
  總共有16篇一級文獻符合篩選規範,這些研究總共包含了6,749名婦女,以尿檢試紙、24小時尿液蛋白尿、尿液蛋白質與肌酸酐比值等估計蛋白尿值,以預測子癲前症的併發症。有10篇研究預測母親的結果;這10篇都顯示蛋白尿對於子癲前症孕婦的併發症預測效果不佳。
  
  為了評估蛋白尿預測胎兒和母親併發症的準確度,有17篇研究使用實驗室檢測,8篇研究使用床邊分析。24小時蛋白尿的閾值是5 g,死產的陽性和陰性檢測結果的總合相似比分別為2.0(95%信心區間[CI]為1.5 - 2.7)與0.53 (95% CI, 0.27 - 1) 、新生兒死亡為1.5 (95% CI, 0.94-2.4) 與0.73 (95% CI, 0.39 - 1.4) 、新生兒加護病房住院為1.5 (95% CI, 1- 2)與0.78 (95% CI, 0.64 - 0.95)。
  
  研究作者寫道,測量蛋白尿對於子癲前症孕婦的母體或胎兒併發症而言,不是一個好的預測指標。
  
  本系統性回顧的限制包括,研究方法學與品質上固有的限制;個別研究在人口、子癲前症定義、檢測方法、檢測閾值與頻率、檢測與結果的間隔、參考標準等的異質性;可能有其他風險因素。
  
  研究作者結論表示,此篇系統性回顧顯示,估計子癲前症孕婦的蛋白尿對於預測胎兒或者母親併發症並無臨床用途。本回顧之結果點出實務上根據蛋白尿嚴重度決定子癲前症孕婦臨床決策的問題。需要對此一重要問題進行更大型、設計良好的前溯研究,希望後續可以更深入探究。
  
  英國Stoke-on-Trent、大學醫院 North Staffordshire研發部支持本研究。研究作者宣告沒有相關財務關係。
  
  BMC Med. 線上登載於2009年3月24日。

Proteinuria May Not Help Predict Fetal or Maternal Outcomes in Preeclampsia

By Laurie Barclay, MD
Medscape Medical News

March 27, 2009 — The estimation of levels of proteinuria in women with preeclampsia is not a clinically useful test to predict fetal or maternal outcomes, according to the results of a systematic review reported in the March 24 Online First issue of BMC Medicine.

"Proteinuria is one of the essential criteria for the clinical diagnosis of pre-eclampsia," write Shakila Thangaratinam, from Birmingham Women's Hospital, United Kingdom, and colleagues. "Increasing levels of proteinuria is considered to be associated with adverse maternal and fetal outcomes. We aim to determine the accuracy with which the amount of proteinuria predicts maternal and fetal complications in women with pre-eclampsia by systematic quantitative review of test accuracy studies."

To identify relevant articles, the investigators performed electronic searches without language restrictions in MEDLINE (1951-2007), EMBASE (1980-2007), the Cochrane Library (2007), and the MEDION database. They also hand searched selected specialty journals and reference citations of retrieved articles. Studies assessing the accuracy of proteinuria estimate to predict maternal and fetal complications of preeclampsia were independently selected by 2 reviewers. With use of maternal and fetal complications as reference standards, 2 x 2 tables were constructed from data extracted on study characteristics, quality, and accuracy.

There were 16 primary articles meeting selection criteria. These studies enrolled a total of 6749?women and evaluated the ability of levels of proteinuria estimated by urine dipstick, 24-hour urine proteinuria, or urine protein-to-creatinine ratio to predict complications of preeclampsia. There were 10 studies predicting maternal outcomes; in all 10 of these, proteinuria was a poor predictor of maternal complications in women with preeclampsia.

To evaluate the accuracy of proteinuria to predict fetal and neonatal complications, 17 studies used laboratory testing and 8 studies used bedside analysis. For the threshold level of proteinuria of 5 g in 24 hours, summary likelihood ratios of positive and negative test results were 2.0 (95% confidence interval [CI], 1.5 - 2.7) and 0.53 (95% CI, 0.27 - 1) for stillbirths, 1.5 (95% CI, 0.94?-?2.4) and 0.73 (95% CI, 0.39 - 1.4) for neonatal deaths, and 1.5 (95% CI, 1- 2) and 0.78 (95% CI, 0.64 - 0.95) for admission to the neonatal intensive care unit.

"Measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia," the study authors write.

Limitations of this systematic review include those inherent in the methodology and the quality of the included studies; heterogeneity between individual studies in population, definition of preeclampsia, method of performing the test, test thresholds and frequency, interval between the test and outcome, and reference standards; and possible confounding by other risk factors.

"This systematic review has shown that estimation of levels of proteinuria in women with [preeclampsia] is not a clinically useful test to predict fetal or maternal complications," the study authors conclude. "The results of this review [call] into question the commonly used practice of making clinical decisions in women with pre-eclampsia based on the severity of proteinuria. It has highlighted the need for large, well-designed prospective studies on this important question with the hope to expand future research."

University Hospital North Staffordshire Research and Development Department, Stoke-on-Trent, United Kingdom, supported this study. The study authors have disclosed no relevant financial relationships.

BMC Med. Published online March 24, 2009.

    
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