关于老年慢性肾脏病诊断标准的争议

Arguements on for diagnostic criteria of chronic kidney disease in elderly

目前的慢性肾脏病(CKD)诊断标准在很多地方忽视了老年人的特殊性。在评估肾功能方面,由于血清肌酐水平受到肌肉含量、饮食等许多因素的影响,因此,所有基于血清肌酐的肾小球滤过率(GFR)评估公式在实际应用特别是在老年人群中应用时均会出现一定的偏倚。近年来,很多研究证实血清胱抑素C是一项干扰因素较少、相对理想的测定GFR的内源性标记物。在CKD分期方面,目前存在的主要问题之一是对老年患者的过度诊断,为此一些学者提出取消CKD 1～2期、将CKD 3期再划分为两部分等建议,然而上述观点仍存在较多争议。此外,为了改善对CKD预后的判断力,有研究者建议将尿白蛋白与估测GFR联合应用,来评估终末期肾病的进展、全因死亡及心血管死亡的风险。本文将对目前临床存在的关于老年慢性肾脏病诊断标准的争议作一综述。

The current diagnostic criteria for chronic kidney disease（CKD） has ignored the particularity of the aged in many aspects.On the assessment of renal function,serum creatinine is affected by many factors,such as the amount of muscle,diet,and so on.Thus all of the creatine-based glomerular filtration rate（GFR） estimations are prone to bias,especially for the elderly.Recently,it has been observed that Cys C may be a more precise endogenous maker of GFR,for it is affected by less factors.On the staging of CKD,one of the major problems is overdiagnosis of old people.It is suggested that stage 1 and 2 should be eliminated and stage 3 needs to be further splited into two parts.However,these considerations remain controversial.Besides,to improve the prognosis evaluation of CKD,it is necessary to combine albuminuria and GFR together to estimate the progression of end-stage renal disease and the risk of all-cause and cardiovascular mortality.