慢性腎臟病篩檢的價值未確定


  【24drs.com】根據美國預防服務工作小組和美國醫師學院臨床實務指引進行的系統性回顧,篩檢和監測慢性腎臟病(CKD)的價值不確定;不過,這篇線上刊載於4月17日內科醫學誌的研究確實發現使用血管加壓素轉化酶抑制劑(ACEIs)和第二型血管張力素受體拮抗劑(ARBs)治療CKD有一些幫助,特別是白蛋白尿和併發糖尿病或心血管疾病的患者。
  
  明尼亞坡里退伍軍人事務醫學中心的Howard A. Fink醫師等人寫道,美國20歲以上成人有11%患有CKD,其中95%屬於早期疾病(第1-3階段),第1-3階段CKD 的盛行率隨著年紀增加,與糖尿病、高血壓及心血管疾病等醫療狀況有強烈關聯。
  
  這篇系統回顧的基本原因是要探討篩檢和監測CKD是否與較早介入而改善臨床結果有關,並且衡量篩檢的利益及風險。
  
  回顧作者搜尋了1985至2011年11月的MEDLINE以及摘錄文獻的書目和專家建議的研究,尋找適當的隨機控制試驗;納入規範包括:以英文發表;評估CKD篩檢、監測或治療;以及臨床結果報告。兩名回顧作者評估了研究方法並確認證據品質和強度。
  
  回顧作者發現,沒有試驗探究篩檢或監測,110篇試驗評估治療方式;雖然間接證據認為,或許可以針對CKD篩檢或監測,這些介入方式的可能效益則未確定。
  
  與安慰劑相比,ACEIs和ARBs與降低末期腎臟病(ESRD)之相對風險(RR)有關,ACEIs相較於安慰劑,ESRD之RRs為0.65 (95%信心區間[CI]為0.49 - 0.88),ARBs相較於安慰劑則為 0.77 (95% CI,0.66 - 0.90);糖尿病和巨白蛋白尿病患接受治療的風險降低效果最大。
  
  微白蛋白尿和心血管疾病或高風險糖尿病患者中,使用ACEIs者的死亡風險低於安慰劑(RR,0.79;95% CI,0.66 - 0.96);估計腎絲球過濾速率不佳、高脂血症或鬱血性心衰竭的患者中,與安慰劑或對照組相比,使用statins和乙型阻斷劑治療與死亡率較低有關,且心血管事件較少。
  
  與一般血壓控制相比,嚴格血壓控制對於降低死亡率之風險、ESRD或其他臨床結果並無任何效用。
  
  使用ARBs和statins類藥物的證據強度高,ACEIs和乙型阻斷劑的證據強度中等,嚴格血壓控制的證據力低。
  
  回顧作者寫道,CKD篩檢或監測對於改善臨床結果的角色還不確定;CKD治療效益之證據以[ACEIs]和[ARBs]最強,白蛋白尿合併糖尿病或心血管疾病者的效果最大。
  
  這篇系統性回顧的可能限制包括,相關結果的證據受限,對試驗對象進行次組事後分析,選擇性報告和出版偏見,此外,少有試驗報告或系統性蒐集副作用資料。
  
  Tufts醫學中心的Katrin Uhlig醫師和Andrew S. Levey醫師在編輯評論中指出,根據這篇回顧的新版指引並無法建議對一般人進行例行性CKD篩檢。
  
  不過,針對有CKD風險因素的病患、急性病患者、診斷性和治療性手術等相關不良結果與CKD風險較高者之篩檢,而非沒有針對性,或許有助於平衡利益與風險和成本。臨床經驗和常識支持檢測這些人的建議。最後,我們需要更多研究來發展可全面掌握CKD治療在各類型族群之各種不同效果的測量方式。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6791&x_classno=0&x_chkdelpoint=Y
  
  

Chronic Kidney Disease Screening of Uncertain Value

By Laurie Barclay, MD
Medscape Medical News

April 16, 2012 — Screening and monitoring for chronic kidney disease (CKD) is of uncertain value, according to a systematic review performed for the US Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline. However, the review, published online April 17 in the Annals of Internal Medicine did find evidence of some benefit for treating CKD with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II-receptor blockers (ARBs), mostly in patients with albuminuria and comorbid diabetes or cardiovascular disease.

"Eleven percent of U.S. adults aged 20 years or older have CKD, of whom 95% have early disease (stages 1 to 3)," write Howard A. Fink, MD, MPH, from the Minneapolis Veterans Affairs Medical Center in Minnesota, and colleagues. "Prevalence of CKD stages 1 to 3 increases markedly with older age and is strongly associated with medical conditions, such as diabetes, hypertension, and cardiovascular disease."

The rationale for this systematic review was to see whether screening and monitoring for CKD would be associated with earlier interventions that would improve clinical outcomes, and to assess the balance of benefits and harms of screening.

The reviewers searched MEDLINE from 1985 through November 2011, as well as bibliographies of retrieved articles and studies suggested by experts, for pertinent randomized controlled trials. Inclusion criteria were publication in English; assessment of CKD screening, monitoring, or treatment; and report of clinical outcomes. Two reviewers evaluated study methods and determined quality and strength of evidence.

The reviewers identified no trials studying screening or monitoring and 110 trials that assessed treatments. Although indirect evidence suggested that it may be possible to target CKD screening or monitoring, the potential benefit of these interventions was uncertain.

Benefits of CKD Treatment

Compared with placebo, ACEIs and ARBs were associated with lower relative risk (RR) for end-stage renal disease (ESRD). RRs for ESRD were 0.65 (95% confidence interval [CI], 0.49 - 0.88) for ACEIs vs placebo and 0.77 (95% CI, 0.66 - 0.90) for ARBs vs placebo. Patients with diabetes and macroalbuminuria had the greatest risk reductions with treatment.

Among patients with microalbuminuria and cardiovascular disease or high-risk diabetes, risk for death was lower with ACEIs than with placebo (RR, 0.79; 95% CI, 0.66 - 0.96). Among patients with impaired estimated glomerular filtration rate and either hyperlipidemia or congestive heart failure, treatment with statins and beta-blockers was associated with lower rates of mortality and cardiovascular events compared with placebo or control.

Compared with usual blood pressure control, strict blood pressure control did not confer any reduction in risk for mortality, ESRD, or other clinical outcomes.

Treatment with ARBs and statins had a high strength-of-evidence rating, whereas the rating was moderate for ACEIs and beta-blockers and low for strict blood pressure control.

Review Limitations and Implications

"The role of CKD screening or monitoring in improving clinical outcomes is uncertain," the review authors write. "Evidence for CKD treatment benefit is strongest for [ACEIs] and [ARBs], and in patients with albuminuria combined with diabetes or cardiovascular disease."

Possible limitations of this systematic review include the limited evidence regarding outcomes, the use of post hoc analyses of subgroups of trial participants, and selective reporting and publication bias. In addition, few trials reported or systematically collected data concerning adverse events.

In an accompanying editorial, Katrin Uhlig, MD, and Andrew S. Levey, MD, from Tufts Medical Center in Boston, Massachusetts, note that new guidelines based on this review are unlikely to recommend regular CKD screening for the general population.

"Nevertheless, targeted screening of clinical populations with a higher risk for CKD and related adverse outcomes, such as patients with CKD risk factors, those with acute illness, and those having diagnostic and therapeutic procedures, rather than untargeted screening may favorably tip the balance of potential benefits versus risks and costs," Dr. Uhlig and Dr. Levey write. "Clinical experience and common sense lend support to recommendations to test these persons. Ultimately, we need more research to develop outcome measures that will comprehensively capture the effect of CKD treatments on the diverse and disparate outcomes encountered in this complex population."

The Agency for Healthcare Research and Quality funded this systematic review and has financial relationships with some of the review authors, including Dr. Fink, who has disclosed receiving a grant from the agency and that his institution has also received a grant from the agency. One coauthor has received payment for the development of educational presentations from PRIME Education. The editorialists have disclosed no relevant financial relationships. Full disclosures can be found at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum_M11-2383.

Ann Intern Med. Published online April 16, 2012.

    
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