血清肌酐和估算的肾小球滤过率对评价冠状动脉介入治疗术患者的比较研究

引用本文

李永姝, 魏超, 王晶, 贾克刚. 血清肌酐和估算的肾小球滤过率对评价冠状动脉介入治疗术患者的比较研究. 2011, 26(10): 679-682
LI Yongshu, WEI Chao, WANG Jing, JIA Kegang. Comparison study of serum creatinine and estimated glomerular filtration rate in the evaluation of the percutaneous coronary intervention in patients. Labratory Medicine, 2011, 26(10): 679-682 复制到剪切板

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《检验医学》编辑部

血清肌酐和估算的肾小球滤过率对评价冠状动脉介入治疗术患者的比较研究

李永姝¹, 魏超², 王晶¹, 贾克刚¹

1. 天津医科大学心血管病临床学院泰达国际心血管病医院检验科,天津 300457

2. 沧州市中心血站检验科,河北 061001

通讯作者:贾克刚,联系电话:022-65208753。

作者简介:李永姝,女,1974年生,学士,主管技师,主要从事免疫学方面的研究。

摘要

目的

比较血清肌酐(SCr)和估算的肾小球滤过率(eGFR)在评价冠状动脉介入治疗(PCI)患者预后的价值。

方法

应用酶法测定1 005例接受PCI患者的SCr和eGFR,采用简化的肾病膳食改良实验(MDRD)方程进行计算。分别用SCr和eGFR作为评价患者肾功能的指标,将患者分为肾功能正常组(SCr-A、eGFR-A)和肾功能损伤组(SCr-B、eGFR-B)。比较SCr-A组和SCr-B组、eGFR-A组和eGFR-B组患者年龄、吸烟、高血压、糖尿病、左室射血分数(LVEF)和术后住院天数的差异,同时评价SCr和eGFR与PCI患者术后3年内发生心脏事件的相关性。

结果

SCr-A和SCr-B组患者除年龄、高血压、LVEF差异有统计学意义外(P<0.05),其余指标差异均无统计学意义(P>0.05)。而eGFR-A和eGFR-B组患者在年龄、吸烟、高血压、糖尿病、LVEF和术后住院天数差异均有统计学意义(P<0.05)。术前SCr与术后3年内发生的心脏事件(MACE)的比值比(OR)为1.006[95%可信区间(CI):0.998~1.014,P=0.146];术前eGFR与术后3年内的心脏事件的OR为0.994(95%CI:0.984~1.003,P = 0.178);单纯的SCr和 eGFR在评价PCI患者预后作用相似,与术后3年内发生MACE无相关性(P>0.05)。

结论

单纯的eGFR和SCr在评估PCI患者的危险分层和预后效果相似。

关键词: 肌酐; 估算的肾小球滤过率; 冠状动脉介入治疗; 预后

中图分类号:R446.1 文献标志码:A 文章编号:1673-8640(2011)10-0679-04

Comparison study of serum creatinine and estimated glomerular filtration rate in the evaluation of the percutaneous coronary intervention in patients

LI Yongshu¹, WEI Chao², WANG Jing¹, JIA Kegang¹

1. Cardiovascular Clinical College of Tianjin Medical University; Department of Clinical Laboratory, TEDA International Cardiovascular Hospital, Tianjin 300457, China

2. Department of Clinical Laboratory, Cangzhou Central Blood Station, Hebei 061001, China

Abstract

Objective

To compare the prognostic value between serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) in the evaluation of percutaneous coronary intervention (PCI) in patients.

Methods

The SCr was determined in 1 005 patients receiving PCI treatment by enzymatic method, and the SCr and eGFR were calculated with improved simplified experimental kidney diet (MDRD) equation. The SCr and eGFR were used as indicators of renal function evaluation, while these patients were classified into 2 groups, group A with normal renal function (SCr-A, eGFR-A) and group B with renal function damage (SCr-B, eGFR-B). The differences of age, smoking, hypertension, diabetes mellitus, left ventricular ejection fraction(LVEF) and the postoperative hospital stay days were analyzed. The correlation of SCr and eGFR with cardiac events for 3 follow-up years was evaluated.

Results

SCr-A and SCr-B group was significantly different in age,hypertension and LVEF (P<0.05), while the eGFR-A and eGFR-B group were statistically different in age, smoking, hypertension, diabetes mellitus, LVEF and postoperative hospital stay days (P<0.05). The odds ratio (OR) in preoperative SCr and postoperative major adverse cardiac events (MACE) occurred within 3 years was 1.006[95% confidence interval (CI):0.998-1.014,P=0.146]. TheOR in preoperative eGFR and postoperative cardiac events after 3 years was 0.994(95%CI:0.984-1.003,P=0.178).

Conclusions

The eGFR and SCr have the similar value as effective indicators in patients scheduled for PCI risk stratification and assessment of of prognosis.

Keyword: Creatinine; Estimated glomerular filtration rate; Coronary intervention; Prognosis

Show Figures

术前肾功能不全被认为是心脏手术后致死率发生的高危因素。肾小球滤过率(GFR)是临床判断肾脏功能的一项重要指标。血清肌酐(SCr)临床上应用广泛,但SCr水平受到年龄、肌肉量等一些因素的影响,只有当GFR下降50%时才开始升高。1999年,Levey等^{[ 1]}开发了肾病膳食改良实验(MDRD)计算方程,该方程仅需测量SCr,结合患者的年龄、性别,即可推算出GFR[即估算GFR(eGFR)]。国内外学者报道在冠状动脉搭桥术评估预后中GFR较SCr评价肾功能更准确,而国外学者报道SCr和eGFR评价急性冠状动脉综合征预后效果相似^{[ 6]}。因此,我们对SCr和eGFR在冠状动脉介入治疗(PCI)患者预后中的作用作了比较研究。

材料和方法

一、对象

选择2004年3月至2007年6月在泰达国际心血管病医院心内科行单纯PCI的患者共1 005例,其中男704例、女301例,年龄3184岁。分别用SCr和eGFR作为评价PCI患者肾功能的指标。根据PCI术前SCr值的不同将患者分为2组:术前肾功能正常组(SCr-A)(SCr ≤106 μmol/L)971例和术前肾功能损伤组(SCr-B)(SCr >106 μmol/L)34例。根据患者eGFR值的不同将其分为术前肾功能正常组(eGFR-A)(eGFR≥60 mL/min) 939例和术前肾功能损伤组(eGFR-B)(eGFR <60 mL/min) 66例。

二、方法

1.样本采集及处理所有研究对象入院行PCI术前清晨空腹采集肘静脉血3 mL,室温下静置30 min后3 500 r/min(离心半径15 cm)离心10 min,上机检测。

2.检测方法在日立7600全自动生化分析仪上采用酶法测定SCr。试剂为日本和光公司产品,校准品及质控物均为配套产品。和光试剂酶法的SCr溯源采用(National Institute of Standards Technology, NIST)参考物质(SRM)914a为标准物质,采用气相色谱-丙基乙二胺-薄层色谱法(GC-PSA-TLC)为SCr定值,未溯源到ID-MS。但和光公司在日立7600全自动生化分析仪上做了和光酶法试剂和罗氏酶法试剂两者的相关分析得出公式: Y=bX+a; b=0 .890, a=1 .283, n=48, R² =0.992 6。用上述公式换算成可溯源至IDMS的日立-罗氏Cr检测系统检测结果,代入MDRD公式。

3.eGFR 用修订的MDRD方程计算,eGFR=175× (SCr/88.4)^-1.154×(年龄)^-0.203×(0.742_女性)。

4.诊疗记录所有患者随访30 d3年(出院患者以电话形式随访,记录心脏事件,包括再入院急性心肌梗死、PCI、冠脉搭桥术和心源性死亡),相同时间多次发生计1次,不同事件连续发生计最严重的事件。高血压诊断依据《中国高血压防治指南》2005年修订版;高血脂诊断依据《中国成人血脂异常防治指南》2007年;糖尿病诊断依据世界卫生组织(WHO)1999年标准。

三、统计学方法

应用SPSS11.5软件包进行统计分析。计量资料以 +s表示,组间差异比较采用 t检验。计数资料用例数、百分数进行描述,组间比较采用卡方检验。 P<0.05表示差异有统计学意义。采用二项logistic回归分析SCr组和eGFR组对术后3年的心脏事件危险度计算比值比( OR)和95%可信区间( CI)。

结果

一、PCI术前SCr组和eGFR组的各项指标比较

SCr-A和SCr-B 组只有年龄、高血压、左室射血分数(LVEF)差异有统计学意义( P<0.05),而eGFR-A组和eGFR-B组年龄、吸烟、高血压、糖尿病、LVEF差异均有统计学意义( P<0.05),见表1。

表1 SCr组和eGFR组在各个方面因素的比较

二、PCI术后SCr组和eGFR组的各项指标的比较

SCr-A和SCr-B 组术后住院天数差异有统计学意义( P< 0.05), eGFR-A组和eGFR-B组术后住院天数差异亦有统计学意义 ( P<0.05),见表2。采用二项logistic回归分析显示术前SCr与术后3年内发生心脏事件的 OR为1.006(95% CI: 0.998~1.014, P=0.146);术前eGFR与术后3年内心脏事件的 OR为0.994(95% CI: 0.984~1.003, P=0.178);单纯的SCr和 eGFR与术后3年内发生心脏事件无相关性( P>0.05)。

表2 SCr组和eGFR组术后住院天数的比较

三、SCr组和eGFR组随访3年中MACE发生率的比较

Scr-A组和SCr-B组MACE发生率差异无统计学意义( P>0.05)。eGFR-A组和 eGFR-B组MACE发生率差异亦无统计学意义( P>0.05)。单纯的SCr组和eGFR组与PCI患者预后MACE发生率无关,不能独立作为PCI患者预后MACE发生的指标。

表3 SCr组和eGFR组随访3年中MACE发生率的比较

讨论

目前慢性肾脏疾病(CKD)的检测和防治已越来越受重视,临床准确评价GFR的变化已越来越重要。外源性标记物^99mTc-DTPA、菊粉清除率测定等方法仍被视为GFR评判的金标准,但其有价格昂贵、需专门的设备、有放射性等缺点。近几年有国外研究表明^{[ 2]},MDRD方程用于评价西方人群GFR,其准确性优于SCr。Francesca等^{[ 3]}对术前肾功能损害严重程度与PCI术后近期预后的关系进行了分析,研究表明评价术前肾功能情况,可作为拟行PCI患者的危险分层和预后评定的有效指标之一。但国内有关方面的报道较少。有国外学者^{[ 4]}报道eGFR对于GFR的评价功效优于SCr,与我们的SCr及eGFR在评价PCI患者预后中的比较研究结果不一致。

本研究结果发现,当使用SCr作为肾功能的筛选指标时,术前肾功能正常者有971例,占96.6%;术前肾功能损伤者有34例,仅占3.4%。而当用eGFR作为筛选指标时,术前肾功能正常者有939例,占93.4%;术前肾功能有损害者有66例,占6.6%。说明eGFR较SCr在评价肾功能损害方面更为精确,能早期反映肾功能情况。由于肾脏具有强大的代偿功能,只有GFR下降50%时SCr才开始升高,SCr无法反映早期的肾功能损害。

SCr-A组和SCr-B组年龄、高血压、LVEF差异有统计学意义( P<0.05),其他均无统计学意义。eGFR-A组和eGFR -B组在年龄、吸烟、高血压、糖尿病和LVEF等方面差异均有统计学意义( P<0.05)。说明了除年龄外日益上升的高血压、糖尿病的患病率可能会对慢性肾病疾病谱产生一定的影响。在术后的评价指标来看,SCr -A组和SCr -B组术后住院天数差异有统计学意义( P>0.05),而eGFR -A组和eGFR -B组术后住院天数差异亦有统计学意义 ( P<0.05)。说明年龄、高血压、LVEF对2组术后都有影响。住院天数的增加,加重了患者的经济负担,说明可以使用eGFR或SCr对PCI患者住院周期进行评价,eGFR与SCr两者在评价PCI患者预后作用相似,与国外学者报道SCr和eGFR在评价急性冠脉综合征预后效果相似的结果一致^{[ 6]}。

本研究结果显示SCr-A组和SCr-B组MACE发生率差异无统计学意义( P>0.05)。而eGFR-A组和 eGFR-B组MACE发生率差异亦无统计学意义( P>0.05)。研究发现术前SCr与术后3年内发生心脏事件的OR值为1.006(95% CI为0.998~1.014, P=0.146);术前eGFR与术后3年内心脏事件的OR值为0.994(95% CI为 0.984~1.003, P=0.178)。说明单一的SCr组和eGFR组和PCI患者术后MACE发生无关,不能独立作为PCI患者预后MACE发生的指标。单一的SCr和 eGFR与术后3年内发生心脏事件无相关性( P>0.05)。与部分研究^{[ 5, 7]}证实了PCI患者术前eGFR的评价是其心脏事件发生的独立危险因素的结果不一致。可能是源于eGFR使用的不足之处,由于MDRD方程基于严重肾衰竭患者的数据开发来的,重度衰竭患者中应用较好,在正常人及血肌酐正常的慢性肾病患者中,MDRD方程可能无法准确估计GFR,有些区域可能有30%50%的误差^{[ 8]}。

同时在本次研究中肾功能损害的研究对象相对较少,还需要更大规模的肾功能损伤标本,进一步确定eGFR在评价PCI术后预后的价值。但本研究结果发现单一eGFR不能替代SCr作为评价PCI患者术后心脏事件发生的一个独立危险因素。单一的SCr和 eGFR在PCI患者术后评估作用相似,可能是单一的eGFR结果在肾功能不全分组时有一定的影响。今后应联合如尿蛋白等定性或定量的检测指标和eGFR对PCI患者术后心脏事件发生的结果进行评价。

The authors have declared that no competing interests exist.

参考文献

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2002

5.294

0.0

... 1999年,Levey等^[1]开发了肾病膳食改良实验(MDRD)计算方程,该方程仅需测量SCr,结合患者的年龄、性别,即可推算出GFR[即估算GFR(eGFR)] ...

1999

13.976

0.0

... 近几年有国外研究表明^[2],MDRD方程用于评价西方人群GFR,其准确性优于SCr ...

2009

3.209

0.0

... Francesca等^[3]对术前肾功能损害严重程度与PCI术后近期预后的关系进行了分析,研究表明评价术前肾功能情况,可作为拟行PCI患者的危险分层和预后评定的有效指标之一 ...

2006

0.0

. 2006, 29(4):461-465 DOI:10.1016/j.ejcts.2006.01.024

Estimated creatinine clearance instead of plasma creatinine level as prognostic test for postoperative renal function in patients undergoing coronary artery bypass surgery

Abstract Background: Preoperative renal failure is a risk factor for adverse events in cardiac surgery. Serum creatinine (SCr) is the most used test for renal failure. However, patients can have significantly decreased glomerular filtration rates with normal SCr levels. More accurate approximation of renal function can be obtained using the Cockroft–Gault equation to calculate an estimated creatinine clearance (CrCl) rate from SCr. Methods: This study included 627 patients undergoing an isolated CABG between January 2003 and September 2004. CrCl was calculated using the Cockroft–Gault formula. Patients were divided in group A-SCr, 576 patients (91.1%) with a good renal function, SCr ≤1.20 mg/dL for women and ≤1.40 mg/dL for men, and a group B-SCr, with impaired renal function, 51 patients (8.1%). CrCl ≤50 mL/min was chosen to reflect renal impairment. Group A-CrCl (555 patients, 88.5%) had a normal renal function and group B-CrCl (72 patients,11.5%) an impaired renal function. The studied outcomes were hospital mortality, hospital morbidity, and postoperative renal failure. Results: There was no statistical significant difference between A-SCr and B-SCr group according to the studied outcomes. On the contrary, using the CrCl there was a statistical significant difference between A-CrCl and B-CrCl for the percentage of postoperative renal failure 10 patients (1.8%) versus 5 patients (6.9%) ( p = 0.00), hospital morbidity 75 patients (13.5%) versus 16 patients (22.2%) ( p = 0.04). Hospital mortality, 11 patients (2%) versus 4 patients (5.6%), was not significantly ( p = 0.06) different. Postoperative dialysis, four patients (0.7%) versus three patients (4.2%) ( p = 0.00), stroke, three patients (0.5%) versus three patients (4.2%) ( p = 0.00), and hospital stay (7.6 days vs 11.0 days) ( p = 0.01) were significantly different. Conclusion: This study documents that the association between preoperative renal failure and adverse outcomes after CABG is stronger with the estimated CrCl than with the routinely used SCr. Routine estimation or measurement of glomerular filtration rate should be preferred to SCr as screening method for the detection of higher risk patients undergoing CABG.

... 有国外学者^[4]报道eGFR对于GFR的评价功效优于SCr,与我们的SCr及eGFR在评价PCI患者预后中的比较研究结果不一致 ...

2008

4.497

0.0

. 2008, 155(6):1027-1032 DOI:10.1016/j.ahj.2008.01.004

Impact of race and chronic kidney disease on 1-year outcome in patients undergoing percutaneous coronary interventions: a single tertiary center experience

Department of Medicine and Division of Cardiology, Emory University, Atlanta, GA

... 与部分研究^[5,7]证实了PCI患者术前eGFR的评价是其心脏事件发生的独立危险因素的结果不一致 ...

2010

5.509

0.0

... 国内外学者报道在冠状动脉搭桥术评估预后中GFR较SCr评价肾功能更准确,而国外学者报道SCr和eGFR评价急性冠状动脉综合征预后效果相似^[6] ...

... 住院天数的增加,加重了患者的经济负担,说明可以使用eGFR或SCr对PCI患者住院周期进行评价,eGFR与SCr两者在评价PCI患者预后作用相似,与国外学者报道SCr和eGFR在评价急性冠脉综合征预后效果相似的结果一致^[6] ...

2008

0.0

. 2008, 9(4):218-223 DOI:10.1016/j.carrev.2008.05.002

Renal impairment is an independent predictor of adverse events post coronary intervention in patients with and without drug-eluting stents

Abstract Renal impairment (RI) is known to be an independent risk factor for the progression of cardiovascular disease. Its impact, however, on the outcomes in patients undergoing percutaneous coronary intervention (PCI) especially in the era of drug-eluting stents (DES) is not well known. We analysed data from patients undergoing PCI from April 1, 2004, to September 30, 2006, who were part of the Melbourne Interventional Group registry. RI was defined as an estimated glomerular filtration rate (eGFR), calculated using Cockcroft–Gault formula, of Four thousand one hundred ninety-five patients (3043 male) with an average age 65±12 years (mean±S.D.) underwent PCI. Twelve-month follow-up was available in 3963 (95%) patients, and these were included in the analysis. One thousand twelve patients (26%) had RI; of these, 608 (60%) presented with an acute coronary syndrome. Both 30-day major adverse cardiac events (MACE), 9.1% vs. 4.6% ( P P P P P RI is an independent predictor of 30-day and 12-month MACE and death after PCI in patients with stable and unstable coronary syndromes, even with widespread use of DES. eGFR should be used to help risk-stratify patients undergoing PCI.

... 与部分研究^[5,7]证实了PCI患者术前eGFR的评价是其心脏事件发生的独立危险因素的结果不一致 ...

2010

0.0

... 可能是源于eGFR使用的不足之处,由于MDRD方程基于严重肾衰竭患者的数据开发来的,重度衰竭患者中应用较好,在正常人及血肌酐正常的慢性肾病患者中,MDRD方程可能无法准确估计GFR,有些区域可能有30%50%的误差^[8] ...