In the history of the development of Chinese and foreign medicine, people have long recognized the importance of the kidneys in maintaining the physiological functions of the human body. However, kidney disease has always been considered a rare disease with a low prevalence. In the past 10 years, from the birth of the concept of chronic kidney disease (CKD) to the development of CKD, it has made great progress in the recognition of CKD. The medical community gradually agrees that CKD is a common chronic non-communicable disease with serious harm, and it is urgent to carry out related research to prevent and treat it. This article intends to review the development process of this new hot spot in the field of kidney disease and briefly describe its possible future trends.
Definition and staging of CKD
In 2002, the American Society of Nephrology published the "Guidelines for the Quality of Life of Kidney Diseases and Dialysis Patients" (K / DOQI Guidelines), which for the first time clearly defined CKD, namely "renal injury and / or glomerular filtration Rate (GFR) <60 ml / (min · 1.73m2), lasting more than 3 months "; this definition has been used so far.
In this guideline, CKD is "one-dimensional" staged according to GFR levels.
Later, prospective cohort studies from large populations suggested that, in addition to GFR levels, urinary albumin levels have independent predictive value for survival prognosis, cardiovascular prognosis, and renal prognosis of CKD patients, and interact with GFR levels. . Therefore, in the recently released CKD guidelines of the Global Kidney Disease Prognosis Organization (KDIGO), a three-dimensional CKD staging system of "CGA" was proposed. In addition to the original GFR classification (G), the system also includes renal etiology (C) and urinary albumin classification (A), aiming to better stratify the risk of CKD patients. The impact of this staging system on research in the field of CKD and its role in clinical practice has yet to be verified over time.
About estimated glomerular filtration rate
Since the basis for the definition and staging of CKD is GFR, research on estimating glomerular filtration rate (eGFR) has naturally become the focus of research. Regarding the eGFR formula based on blood creatinine, it is currently believed that the Chronic Kidney Disease Epidemiology Cooperation (CKD-EPI) formula released in 2009 can be more accurately estimated than the formula developed by the Kidney Disease Diet Adjustment Research (MDRD) Working Group GFR, and can predict the poor prognosis more accurately, so it is recommended.
A newly published verification study shows that among many formulas, the "two races" CKD-EPI formula (Chinese people use the "non-black" racial level) performs similarly and best to the Chinese formula.
In addition, some scholars have tried to incorporate Cystatin C into the GFR estimation formula. The newly released research results of the CKD-EPI collaboration group show that the eGFR formula including both blood creatinine and Cystatin C performs better. However, considering the increase in cost caused by the addition of Cystatin C testing, and with the promotion of Cystatin C testing, the shortcomings of this testing project are also emerging, and currently only recommended for eGFR is 45 ~ 59 ml / (min · 1.73m2 ), And adults who are not accompanied by other indicators of kidney damage, further test Cystatin C to determine whether CKD is present. Whether other biomarkers will be included in the eGFR formula to improve accuracy is also a possible development direction in the future.
Randomized controlled clinical trial on CKD
As we all know, compared with the cardiovascular field, there are few randomized controlled clinical trials (RCT) in the kidney field, which may be related to the lack of candidate intervention targets. The newly published Heart and Kidney Protection Study (SHARP Study) is by far the largest RCT in the CKD field. The study showed that compared with the placebo group, the number of severe atherosclerosis events in the simvastatin plus ezetimibe group was reduced by 17%.
In addition, RCTs on delaying the progression of CKD patients and preventing and treating CKD-related complications (especially cardiovascular diseases) will also be launched one after another, including the evaluation of the effects of some new drugs, which will inevitably bring CKD intervention More evidence.
Cohort study on CKD
Compared with cross-sectional studies, cohort studies have more advantages and can provide information on morbidity and provide reliable data for monitoring disease burden trends and interventions. For the emerging research field of CKD, cohort research is undoubtedly a more appropriate research design at this stage.
Internationally, the CKD Prognostic Collaboration Group (CKD-PC) conducted a meta-analysis of data from individual prospective cohorts from dozens of prospective cohorts around the world. A large number of high-quality studies have been published on the prognosis and risk factors of CKD, which has contributed to a deeper comprehensive understanding of CKD.
The Chronic Renal Insufficiency Cohort (CRIC) study from the United States has been initiated since 2001 and has included 4,000 patients with CKD. The study design and execution are extremely rigorous, thus ensuring the reliability of the study results.
At present, this research has been developed to cooperative projects in Asia (Japan, China) and Germany, and the scale is constantly expanding. To date, the most influential research result of CRIC is to reveal the independent predictive effect of fibroblast growth factor-23 (FGF-23) level on the survival prognosis of CKD patients. China has already carried out technical cooperation with the CRIC study and initiated the "Multi-center Prospective Cohort Study of Chinese Chronic Kidney Diseases" (C-STRIDE) led by the Department of Nephrology, Peking University First Hospital. The study involves 33 research centers across the country, and it is planned to conduct long-term follow-up of 3,000 patients with CKD.
A cross-sectional study on the prevalence of CKD
After the publication of the K / DOQI guidelines in 2002, with the upsurge in the international CKD prevalence survey, China has also conducted many regional studies on the prevalence of CKD in different regions. The newly published "Chinese Chronic Kidney Disease Epidemiology Survey" provides nationwide survey data.
The study was led by the Department of Nephrology, Peking University First Hospital, and participated in 13 major hospitals nationwide. The study used a multi-stage stratified sampling method to obtain a survey population that can represent the situation of China's adult population over 18 years of age. The results of this study show that China's CKD disease burden is heavy, and the risk factors are mostly hypertension, diabetes and hyperuricemia related to poor lifestyles. Therefore, the early prevention and treatment plan of CKD should be integrated into the management plan of other related chronic diseases. The main results of this study are shown in the figure above.
These results provide important evidence for the prevention and treatment of CKD. However, the scientific questions that can be answered by cross-sectional studies are limited, and it is of little significance to continue to carry out cross-sectional studies of the prevalence of CKD in the general population in the future.
summary
In summary, CKD is a hot research field that has been progressing rapidly in the past 10 years, and its understanding has been deepened. It can be predicted that in the next 10 years, influential new research results will continue to emerge in this field, and it is expected that these results can be finally applied to the prevention and control of CKD and improve the prognosis of CKD patients.
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