2种风险预测模型在慢性肾脏病患者动脉粥样硬化风险预测中的价值

Value of 2 risk prediction models in predicting the risk of atherosclerosis in patients with chronic kidney disease

目的:慢性肾脏病(chronic kidney disease,CKD)患者的心血管疾病(cardiovascular disease,CVD)发生率高,动脉粥样硬化(atherosclerosis,AS)是CVD的主要病理基础。动脉粥样硬化性心血管疾病(atherosclerotic cardiovascular disease,ASCVD)是CKD患者的主要并发症和死亡原因之一。关注并监测AS风险是多学科综合治疗理念的体现。通过连续监测AS相关危险因素可早期发现高危人群,早期改变AS危险因素,以改善CKD患者的预后及生存质量,降低CKD患者的CVD病死率。纳入多因素分析的Framingham风险预测模型及国人10年ASCVD风险预测模型能综合评估、预测AS风险,其在普通人群中的使用价值已得到广泛证实,而在CKD人群的适用性需进一步探究。本研究旨在分析2种风险预测模型对CKD人群AS风险的预测价值,寻找预测CKD患者AS风险的简便且可靠的方法。方法:本研究为横断面研究。选取CKD患者146例及健康对照者14例,应用颈动脉超声检查测量左、右侧颈动脉内膜-中膜厚度以评估AS患病情况。采集受试者病史、体格检查及实验室检查结果进行Framingham风险评分(Framingham Risk Score,FRS)及ASCVD评分以预测AS风险。比较CKD组与对照组的基线资料及AS阳性率,并将FRS及ASCVD评分检出的AS阳性率与颈动脉超声检查检出的AS阳性率进行Kappa一致性检验及真实性、可靠性及收益的综合比较。结果:CKD组与对照组的性别、年龄及BMI差异均无统计学意义(均P>0.05)。CKD组的收缩压、舒张压、脉压、总胆固醇、三酰甘油、低密度脂蛋白胆固醇、血尿素氮、血肌酐及糖化血红蛋白水平显著高于对照组(均P<0.05),而高密度脂蛋白胆固醇、肾小球滤过率均显著低于对照组(均P<0.05)。FRS、ASCVD评分及颈动脉超声检查3种方法检出的CKD患者AS阳性率分别为43.84%、53.42%及46.58%,均显著高于对照组(均P<0.01)。3种方法检出的CKD患者AS阳性率差异无统计学意义(P=0.24)。FRS与ASCVD评分检出的AS阳性率具有高度一致性(Kappa值=0.647,P<0.001),FRS与颈动脉超声检查检出的AS阳性率具有中度一致性(Kappa值=0.447,P<0.001),ASCVD评分与颈动脉超声检查检出的AS阳性率具有一致性(Kappa值=0.373,P<0.001)。FRS和ASCVD评分对预测CKD患者AS风险的灵敏度分别为67.65%和73.53%,特异度分别为76.92%和64.10%。FRS、ASCVD评分并联使用的灵敏度为91.44%、特异度为49.31%,串联使用的灵敏度为49.74%、特异度为91.71%。结论:2种风险预测模型检出的CKD患者AS阳性率与颈动脉超声检查无明显差异且具有较好的一致性和符合率,对预测CKD患者的AS风险具有较好的应用价值,联合应用可进一步提高诊断的灵敏度或特异度。

Objective:Cardiovascular disease(CVD)remains a high morbidity in patients with chronic kidney disease(CKD),and atherosclerosis(AS)is the main pathological basis of CVD.Atherosclerotic cardiovascular disease(ASCVD)is one of the major complications and causes of death in CKD patients.Monitoring and paying attention to the risk of AS is the manifestation of multidisciplinary comprehensive treatment.Through continuous monitoring the risk factors of AS,patients with high AS risk can be detected early,and then risk factors can be treated to improve the prognosis and life quality of CKD patients and reduce the CVD mortality of CKD.The Framingham risk prediction model and Chinese 10-year ASCVD risk prediction model can comprehensively evaluate the AS risk.The predictive value of the 2 risk prediction models has been widely confirmed in the general population,but the application in CKD population needs to be further explored.Thus,the aim of this study is to analyze the value of the 2 risk prediction models in predicting AS risk of CKD population and to find a simple and reliable method to predict AS risk of CKD population.Methods:This study was a cross-sectional study and 146 CKD patients(CKD group)and 14 healthy controls(control group)were recruited.Carotid ultrasound examination was performed to measure the intima-media thickness of left and right carotid arteries to evaluate the prevalence of AS.Medical history,physical examination,and clinical laboratory test data were collected to calculate Framingham Risk Score(FRS)and ASCVD score for all participants.We compared baseline data and AS positive rate between the CKD group and the control group.The AS positive rates detected by FRS,ASCVD score,and carotid ultrasound examination were compared in terms of Kappa consistency test,authenticity,reliability,and benefits.Results:There were no significant differences in sex,age,and BMI between the CKD group and the control group(all P>0.05).The levels of systolic blood pressure,diastolic blood pressure,pulse pressure,total cholesterol,triglyceride,low density lipoprotein cholesterol,blood urea nitrogen,serum creatinine,and glycosylated hemoglobin in the CKD group were significantly higher than those in the control group(all P<0.05),while high density lipoprotein cholesterol and glomerular filtration rate were significantly lower than those in the control group(both P<0.05).The positive rates of AS in the CKD group detected by FRS,ASCVD score,and carotid ultrasound examination(43.84%,53.42%,and 46.58%,respectively)were all significant higher than those in the control group(all P<0.01).There was no significant difference in the positive rate of AS in the CKD group among the 3 methods(P=0.24).The AS positive rate detected by FRS was highly consistent with ASCVD score(Kappa value was 0.647,P<0.001),FRS was moderately consistent with carotid ultrasound examination(Kappa value was 0.447,P<0.001),and ASCVD score was consistent with carotid ultrasound examination(Kappa value was 0.373,P<0.001).The sensitivities of FRS and ASCVD score were 67.65%and 73.53%,respectively,the specificities were 76.92%and 64.10%,respectively.The sensitivity was 91.44%and specificity was 49.31%when FRS and ASCVD score were used in parallel.And the sensitivity was 49.74%and the specificity was 91.71%when FRS and ASCVD score were used in series.Conclusion:The positive rates of AS in CKD patients detected by risk prediction models are not different from that detected by carotid artery ultrasound,and there are good consistency and coincidence rate among risk prediction models and carotid artery ultrasound.Risk prediction models are suitable for predicting the risk of AS in patients with CKD,and the combined application of them can further improve the sensitivity or specificity of diagnosis.