Lancet：慢性肾病是与糖尿病等同的心梗预测因子
2012-06-21 范振光 爱唯医学网
《柳叶刀》(Lancet)杂志6月19日在线发表的一项研究显示，慢性肾病(CKD)患者发生心肌梗死(MI)的风险与糖尿病患者一样高，并且前者的死亡风险甚至更高(Lancet 2012 June 19 [doi:10.1016/S0140-6736(12)60572-8])。 这项研究由加拿大阿尔伯塔大学医学和公共卫生学系的Marcello Tonelli博士及其同事进行，
《柳叶刀》(Lancet)杂志6月19日在线发表的一项研究显示，慢性肾病(CKD)患者发生心肌梗死(MI)的风险与糖尿病患者一样高，并且前者的死亡风险甚至更高(Lancet 2012 June 19 [doi:10.1016/S0140-6736(12)60572-8])。
这项研究由加拿大阿尔伯塔大学医学和公共卫生学系的Marcello Tonelli博士及其同事进行，研究对象来自阿尔伯塔肾病网络和2003~2006年全美健康营养调查(NHANES)这两个大型人群队列，旨在比较有MI病史的成人患者、无肾病的糖尿病成人患者和无糖尿病的CKD成人患者的MI住院风险。
结果显示，在中位随访4年期间，1,268,029例受试者中有1%(11,340)因MI住院。与健康成人相比，有MI病史的患者随访期间的未校正MI发生率最高(18.5/1,000人-年)，而糖尿病患者(5.4/1,000人-年)和CKD患者(6.9/1,000人-年)的该发生率也显著增加。此外，CKD患者MI住院30天内的死亡率最高(14%)，而糖尿病患者(8%)和有MI既往史的患者(10%)的该死亡率也显著增加。
校正患者年龄、社会经济地位和合并症后分析发现，CKD患者的MI发生率降低，但糖尿病患者的MI发生率未降低。这表明，CKD患者的心血管风险主要可归因于人口学和临床特征(主要为老龄)。
该研究表明，与糖尿病一样，可考虑将CKD作为冠心病等危症。这意味着，与糖尿病患者一样，CKD患者发生冠脉事件的风险与既往有心脏病发作的患者相当。此外，与糖尿病患者一样，CKD患者可从降脂治疗中获益。
在随刊述评中，芝加哥大学心脏病学科的Tamar S. Polonsky博士与内分泌、糖尿病与代谢科的George I. Bakris博士指出，由于校正患者年龄、性别和合并症后，CKD患者的MI发生率低于糖尿病患者和有MI既往史的患者，不支持将CKD归为冠心病等危症。不过，仍有充分理由支持对CKD患者实施降脂治疗。CKD患者的MI发生率远高于一般人群，他汀类药物可降低CKD患者的动脉粥样硬化事件，并且安全性较好(Lancet 2012 June 19 [doi:10.1016/So140-6736(12)60772-7])。
该研究获阿尔伯塔医学研究遗产基金会等机构支持。Tonelli博士与辉瑞和默沙东公司存在联系。Bakris博士与武田等多家公司存在联系。
Chronic Kidney Disease, Diabetes Equivalent MI Predictors
The risk of myocardial infarction is just as high in patients who have chronic kidney disease as in those who have diabetes, and their subsequent mortality is even higher, according to a report published online June 19 in the Lancet.
“Our research suggests that there is a strong case for considering CKD to be a coronary heart disease risk equivalent,” as is the case with diabetes. This means that people with CKD, like diabetes patients, “are at a comparable risk of coronary events to those who have previously had a heart attack,” Dr. Marcello Tonelli of the departments of medicine and public health sciences at the University of Alberta, Edmonton, said in a press statement accompanying the release of the report.
Dr. Tonelli and his associates used information from two large, population-based cohorts – the Alberta Kidney Disease Network and the U.S. National Health and Nutrition Examination Survey (NHANES) 2003-2006 – to compare the risks of hospitalization for MI among adults with previous MI, adults with diabetes mellitus but no kidney disease, and adults with CKD but no diabetes. The 1,268,029 study subjects were followed for a median of 4 years, during which time 1% (11,340) were admitted for MI.
Compared with healthy adults, the unadjusted rate of MI during follow-up was highest in people with a history of MI (18.5 per 1,000 person-years) but was also significantly elevated in those with diabetes (5.4 per 1,000 person-years) or CKD (6.9 per 1,000 person-years).
In addition, the proportion of patients who died within 30 days of admission for MI was highest for patients with CKD (14%) but also was significantly elevated for patients with diabetes (8%) and those with a history of MI (10%).
These findings suggest that “arguments supporting inclusion of diabetes in the highest risk category for CHD seem also to apply to people with CKD,” the investigators said (Lancet 2012 June 19 [doi:10.1016/S0140-6736(12)60572-8]).
In exploratory analyses in which the data were adjusted to account for patient age, socioeconomic status, and comorbidities, the MI rate decreased in those with CKD but not in those with diabetes. This suggests that demographic and clinical characteristics – most notably, old age – are responsible for much of the cardiovascular risk associated with CKD, they noted.
The study findings also imply that patients with CKD, like those with diabetes, would benefit from lipid-lowering treatment.
In an editorial comment accompanying Dr. Tonelli’s report, Dr. Tamar S. Polonsky and Dr. George I. Bakris said that the findings actually argue against classifying CKD as a coronary heart disease risk equivalent because, after the data were adjusted to account for patient age, sex, and comorbidities, the rate of MI was lower in patients with CKD than in those with diabetes or previous MI (Lancet 2012 June 19 [doi:10.1016/So140-6736(12)60772-7]).
Nevertheless, despite these negative findings for the primary outcome of this study, there still are compelling reasons to consider lipid-lowering therapy in patients with CKD. Statins reduce the incidence of atherosclerotic events and appear to be safe in adults with CKD, whose rates of MI far exceed those in the general population, wrote Dr. Polonsky of the section of cardiology at the University of Chicago and Dr. Bakris of the section of endocrinology, diabetes, and metabolism and the ASH Comprehensive Hypertension Center at the University of Chicago.
This study was supported by the Alberta Heritage Foundation for Medical Research, Alberta Health and Wellness, the University of Alberta, and the University of Calgary. Dr. Tonelli reported ties to Pfizer and Merck, and one of his associates reported ties to Amgen. Dr. Bakris reported ties to Takeda, Novartis, Abbott, Roche, Lilly, and Forest Laboratories.
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