腎臟健康檢測優於其他的心臟風險檢測


  【24drs.com】根據線上發表於5月28日Lancet糖尿病與內分泌學期刊、共超過60萬名研究對象的一篇統合分析,估計腎絲球過濾速率以及白蛋白尿都可以獨立預測心血管死亡率與心臟衰竭。
  
  第一作者、約翰霍普金斯彭博公衛學院的Kunihiro Matsushita博士表示,希望我們的研究結果可以鼓勵醫師們對於糖尿病、高血壓、腎臟病患者都要評估腎功能與損傷,考慮腎臟病相關資訊以釐清患者的心血管風險。
  
  重要的是,醫師們已經有他們必須評估的數據。研究者指出,最常用的腎功能檢測是估計腎絲球過濾速率(eGFR),檢視腎臟過濾血液的情況,美國每年進行大約2億9千萬次這項檢測。
  
  另一項檢測是白蛋白與肌酸酐的比率(ACR),檢測尿液中的蛋白質,以判斷腎臟的損傷情況,糖尿病、高血壓、腎臟病患者都常進行這項檢測。
  
  Matsushita博士表示,我們的資料顯示,使用這類資訊可以幫助醫師預測未來的心血管風險,且優於使用傳統的風險因素。
  
  研究者分析了參加「Chronic Kidney Disease Prognosis Consortium」的637,315名沒有心血管病史的研究對象,研究者發現eGFR值和白蛋白尿都可以獨立預測心血管疾病,特別是心衰竭與死於心臟病發作及中風。
  
  在預測心衰竭或死於心臟病發作或中風,ACR是比較強的預測因子 — 優於膽固醇或收縮壓、甚或不論患者是否為抽菸者。
  
  這些資料支持指引呼籲對糖尿病、高血壓與慢性腎病患者進行腎臟檢測,但是,Matsushita博士認為這些資料也支持更廣泛地運用。舉例來說,ACR在黑人比白人是更有效的預測因子。他指出,需要後續研究與成本分析來確認如何廣泛進行這些檢測。
  
  他表示,我們並不是要消除現有的檢測,但是,在這些檢測之外,腎臟檢測可以獲得更好的預測。
  
  Matsushita博士表示,對於慢性腎病患者,同時使用eGFR和ACR對於心血管疾病是更好的預測因子,優於多數的傳統風險因子。相較於其他任何一個可以調整之傳統預測因子小於0.007,省略eGFR和ACR之後,心血管死亡率的一致性統計量(C-statistics)降低約0.0227 (95%信賴區間 0.0158 - 0.0296)。
  
  這項資訊特別重要,因為慢性腎病患者發生心血管疾病的風險是腎臟健康者的兩倍之多,且其中約有半數在發生腎衰竭之前即死於心血管疾病。
  
  他表示,心血管預測的改善在糖尿病患更是明顯,研究結果對現有的臨床指引包括評估腎臟病增加支持。
  
  西班牙Autonoma de Madrid大學腎臟與高血壓科Alberto Ortiz博士與Beatriz Fernandez-Fernandez醫師在編輯評論中表示,這篇研究為哪些檢測對於心血管疾病是好的預測因子提出定論,但是也提出了其他問題。
  
  這些問題包括,病理尿液ACR會不會增加風險,如果會,怎麼辦?白蛋白尿會不會促進腎臟發炎與減少(抗衰老基因)klotho之表現,導致阻抗成纖維細胞生長因子23(fibroblast growth factor-23)的高磷酸鹽尿?白蛋白尿、發炎或磷酸鹽是否可能是潛在的治療目標?
  
  不過,他們表示,基於這些結果,臨床指引的作者們,特別是聚焦在預防心血管死亡者,應考慮將尿液ACR納入估計心血管風險的計算。
  
  明尼蘇達州羅徹斯特梅約診所腎臟與高血壓科主任、醫學副教授Robert Albright醫師表示,這篇研究提供更多資料鼓勵政策制定者對一般人提供慢性腎病篩檢。
  
  他指出,美國醫師學院建議對沒有糖尿病的患者進行白蛋白尿例行篩檢。他們沒有感覺到文獻支持它,而我認為這篇研究之強度足以讓這些篩檢納入一般健康檢測的一部分。
  
  資料來源:http://www.24drs.com/
  
  Native link:Kidney Health Measures Beat Other Tests for Heart Risk

Kidney Health Measures Beat Other Tests for Heart Risk

By Marcia Frellick
Medscape Medical News

Estimated glomerular filtration rate and albuminuria independently predict cardiovascular mortality and heart failure, according to a meta-analysis of individual data from more than 600,000 study participants published online May 28 in the Lancet Diabetes and Endocrinology.

Lead author Kunihiro Matsushita, MD, PhD, from Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, told Medscape Medical News, "I hope our results will encourage physicians to assess both kidney function and damage among those with diabetes, hypertension and kidney disease, and consider the information on kidney disease to classify cardiovascular risk of the patient."

Importantly, physicians may already have the numbers they need for assessment. The most common test for kidney function is estimated glomerular filtration rate (eGFR), which checks how well kidneys are filtering blood. That test is given approximately 290 million times a year in the United States, the authors note.

Another test is the albumin-to-creatinine ratio (ACR), which measures protein in the urine to check for kidney damage. The test is commonly given, especially to those with diabetes, hypertension, and kidney disease.

"Our data demonstrated that the use of that kind of information can help physicians predict future cardiovascular risk better than when they use traditional risk factors," Dr Matsushita said.

The researchers analyzed data from 637,315 participants with no history of cardiovascular disease in the Chronic Kidney Disease Prognosis Consortium. The investigators found that both eGFR levels and albuminuria independently predicted cardiovascular disease, particularly heart failure and death from heart attack and stroke.

ACR was the stronger predictor — stronger than cholesterol or systolic blood pressure, or even whether someone was a smoker — in predicting heart failure or death from heart attack or stroke.

The data support guidelines that call for the kidney tests among those with diabetes, hypertension, and chronic kidney disease, but Dr Matsushita suggests the data may also support wider use. For instance, ACR was a more effective predictor among blacks than among whites, he said. Determining how widely the tests should be administered would take further study and cost analysis, he added.

Measures Not Meant to Replace Tests

"Our intention is not to eliminate existing tests," he said, but on top of those tests, "kidney measures can contribute to better prediction."

Dr Matsushita said using both eGFR and ACR in combination was a better predictor of cardiovascular disease than almost all traditional risk factors among people with chronic kidney disease. The C statistic for cardiovascular mortality dropped by 0.0227 (95% confidence interval, 0.0158 - 0.0296) after omission of eGFR and ACR compared with less than 0.007 for any single modifiable traditional predictor.

The information is especially important because people with chronic kidney disease are twice as likely as those with healthy kidneys to develop cardiovascular disease, and about half of them die from cardiovascular disease before they reach kidney failure.

Improvement of cardiovascular prediction was more evident among those with diabetes, he said. Study results add support to use of existing clinical guidelines, which include assessment for kidney disease.

In an accompanying comment, Alberto Ortiz, MD, PhD, and Beatriz Fernandez-Fernandez, MD, from the Nephrology and Hypertension Department at the Universidad Autonoma de Madrid in Spain, say the study settles the question of whether the tests are a good predictors of cardiovascular disease, but raises other questions.

Among them are, "Could pathological urinary ACR cause the increased risk, and if so, how? Could albuminuria promote kidney inflammation and decrease klotho expression, leading to resistance to the phosphaturic effect of fibroblast growth factor-23? Would albuminuria, inflammation, or phosphate thus be potential therapeutic targets?"

They say, however, that given the results, authors of clinical guidelines, especially those focused on preventing cardiovascular deaths, should consider incorporating urinary ACR into algorithms for estimating cardiovascular risk.

Robert Albright, DO, associate professor of medicine and chairman of the Division of Nephrology and Hypertension at the Mayo Clinic, Rochester, Minnesota, said this study may be one more bit of data that could encourage policy writers to address screening for chronic kidney disease in the general population.

He noted that the American College of Physicians recommends against routine screening for albuminuria in patients without diabetes.

"They didn't feel the literature supported it," he told Medscape Medical News. "I think this study may ask the powers that be to readdress whether these screening tests should be part of a population health strategy."

The study was supported by the US National Kidney Foundation, National Institute of Diabetes and Digestive and Kidney Diseases. Dr Matsushita reports receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases and personal fees from Mitsubishi Tanabe Pharma, Kyowa Hakko Kirin, and MSD outside the submitted work. Several coauthors report receiving funding from Amgen, Servier, Novartis, Astellas, Alexion, and Sanofi. One coauthor has a patent pending regarding provisional patent submitted for GFR estimation using a panel of biomarkers. Dr Ortiz has received consultancies, honoraria, or speakers' fees from Sanofi, Fresenius Medical Care, Amgen, Rovi, and Servier, and travel or accommodation payments from Sanofi, Fresenius Medical Care, Shire, and AbbVie. Dr Fernandez-Fernandez has received consultancies, honoraria, or speakers' fees from Genzyme, AbbVie, and Astra Zeneca, and travel or accommodation payments from AbbVie. Their research is supported by ISCIII FIS PI13/00047, PIE13/00051, RETIC REDinREN FEDER funds RD12/0021, Programa Intensificacion Actividad Investigadora (ISCIII/CAM), and Joan Rodes.

Lancet Diabetes Endocrinol. Published online Mary 28, 2015. Article abstract,

    
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