儿童肾小球滤过率的临床应用

doi:10.12372/jcp.2022.22e1222

临床儿科杂志 ›› 2022, Vol. 40 ›› Issue (12): 886-893.doi: 10.12372/jcp.2022.22e1222

儿童肾小球滤过率的临床应用

高春林

东部战区总医院儿科南方医科大学第一临床医学院南京临床医学院（东部战区总医院）儿科南京大学医学院附属金陵医院（东部战区总医院）儿科南京医科大学附属金陵临床医学院（东部战区总医院）儿科（江苏南京 210002）

收稿日期:2022-09-13 出版日期:2022-12-15 发布日期:2022-12-06
作者简介:高春林，博士，ORCID：0000-0001-8113-311X，硕士生导师，儿科学博士，博士后，长期从事儿科肾脏病临床、教学、科研工作，对儿童肾病综合征、紫癜性肾炎、IgA肾病、狼疮性肾炎、遗尿症、遗传性肾脏病等擅长。已发表SCI论文20余篇，核心期刊论文20余篇；主持国家自然科学基金1项，参与省部级课题2项；获教育部自然科学奖二等奖1次，江苏省医学科技奖二等奖1项，军队医疗成果二等奖1次，江苏省新技术引进奖4项；获得“2020年中国儿科肾脏病十大青年精英”称号，江苏省第六期“333高层次人才培养工程”培养对象；参编专著4本，专利2项。担任中华医学会儿科学分会儿肾学组委员、江苏省医学会儿科学分会副主委、江苏省医学会儿肾学组副组长、全军儿科学青年委员、江苏省医学会遗传学会委员、江苏省预防医学会儿童保健学组委员、江苏省医学会儿童保健学组委员，任临床儿科杂志、中华儿科杂志、东南国防医药杂志编委。
基金资助:
江苏省儿科医学创新团队项目(CXTDA2017022)

Clinical application of glomerular filtration rate in children

GAO Chunlin

Department of Pediatrics, Nanjing General Hospital of Nanjing Military Region, Southern Medical University Clinical Medical College, Nanjing 210002, Jiangsu, China

Received:2022-09-13 Online:2022-12-15 Published:2022-12-06

摘要/Abstract

摘要：

肾小球滤过率(GFR)是衡量肾脏功能状态的重要指标之一，临床中用于诊断慢性肾脏疾病 (CKD)及其分期、肾移植供者选择、科学研究终点事件设定等，也是肿瘤治疗监测及危急重症治疗临床药物剂量调整、药物毒性监测、新药研发等领域不可或缺的指标。儿童GFR的评估可采用估算法和检测法。估算法是具有临床实用性，目前用于儿童eGFR的方程具有种族和地域特性，准确性受开发数据集人群的影响。国内以Schwartz 1987版应用较多，需注意该方法肌酐测定法为比色法，Schwartz2009方程亦有较广泛的应用，但在我国CKD儿童中准确性（P₃₀）均较低，未超过80%。目前迫切需要新的大样本的来自于中国儿童的估算方程。在需要精确获得GFR 的情况下，临床采用测定GFR的方法。文章介绍了用于估算和测量GFR指标的优缺点和在GFR儿科的应用现状。

关键词: 肾小球滤过率, Schwartz公式, 肾功能, 儿童

Abstract:

Glomerular filtration rate (GFR) is one of the important indicators to measure renal function status. It is used in the clinical diagnosis of chronic kidney disease (CKD) and its staging, selection of kidney transplant donors, setting of endpoint events in scientific research, etc. It is also an indispensable index in the fields of cancer treatment monitoring, clinical drug dose adjustment in ICU critical care treatment, drug toxicity monitoring and new drug development. GFR in children can be assessed by both estimation and detection. The estimation method has clinical practicability. The current equations used for eGFR in children are ethnically and geographically specific, and their accuracy is influenced by the population of the developed dataset. Schwartz 1987 version is widely used in China. It should be noted that this method is a colorimetric method for creatinine determination. Schwartz 2009 equation is also widely used, but its accuracy (P₃₀) in Chinese children with CKD is low, which is less than 80%. New estimating equations from large samples of Chinese children are urgently needed. In cases where accurate GFR is required, the method of measuring GFR is used. This paper introduces the advantages, disadvantages and application status of indicators used to estimate and measure GFR in pediatrics.

Key words: glomerular filtration rate, Schwartz formula, renal function, child

高春林. 儿童肾小球滤过率的临床应用[J]. 临床儿科杂志, 2022, 40(12): 886-893.

GAO Chunlin. Clinical application of glomerular filtration rate in children[J]. Journal of Clinical Pediatrics, 2022, 40(12): 886-893.

图/表 4

表1

表2

表3

表4

关于Schwartz公式"

名称	公式
Schwartz1976	eGFR=0.43×身高（cm）/肌酐（mg/dL） eGFR=38×身高（cm）/肌酐（μmol/L）
Original Schwartz 1987 初始Schwartz 1（肌酐比色法）	eGFR=k×身高（cm）/肌酐（mg/dL），早产儿k= 0.33，足月儿k=0.45，儿童加女性k=0.55, 青春期男孩k= 0.7
初始Schwartz 2（肌酐比色法）1987	eGFR=k×身高（cm）/血肌酐（μmol/L），0~18个月k 40，2~16 岁女孩、2~13岁男孩49， 13~16岁男k 62
Updated Schwartz “bedside” (CKiDCr)2009 升级版Schwartz床旁公式(CKiDCr)2009（肌酐酶法）	eGFR=0.413×身高（cm）/血肌酐（mg/dL） eGFR=36.2×身高（cm）/ 血肌酐（μmol/L）
CKiDCys C (Schwartz “bedside” cystatin C2009 Schwartz床旁公式胱抑素C 2009	eGFR=70.69×[胱抑素 C（mg/L）]^-0.931
CKiD Cr - Cys-C (combined CKiD creatinine-cystatin C)2009 Schwartz床旁公式肌酐联合胱抑素C 2009（肌酐酶法）	女39.1×（身高/肌酐）^0.516×（1.8/胱抑素C）^0.294×（30/尿素氮）^0.169×（身高/1.4）^0.188 男39.1×（身高/肌酐）^0.516×（1.8/胱抑素C）^0.294×（30/尿素氮）^0.169×1.099×（身高/1.4）^0.188
Updated Schwartz “bedside” (CKiDCr)2012 升级版Schwartz床旁公式肌酐2012（肌酐酶法）	eGFR=42.3×（身高/肌酐）^0.79
CKiDCys C (Schwartz “bedside” cystatin C2012 Schwartz床旁公式胱抑素C 2012	eGFR=（70.69×胱抑素C）^-0.931
CKiD Cr - Cys-C (combined CKiD creatinine-cystatin C)2012 Schwartz床旁公式肌酐联合胱抑素C 2012（肌酐酶法）	女eGFR=39.8×[身高（m）/肌酐（mg/dL）]^0.456×[1.8/胱抑素C （mg/L）]^0.418×[30/尿素氨（mg/dL）]^0.079×[身高（m）/1.4]^0.179 男eGFR=39.8×[身高（m）/肌酐（mg/dL）]^0.456×[1.8/胱抑素C（mg/L）]^0.418×[30/尿素氨（mg/dL）]^0.079×[1.076]×[身高（m）/1.4]^0.179
Schwartz-Lyon Schwartz里昂（肌酐比色法）	eGFR=k×身高/肌酐，<13岁男孩、女性<18岁k=36.8，其余年龄性别k=41.3
CKiD under 25（肌酐酶法） CKiD U25	k×身高/肌酐（mg/L） k×1/胱抑素C

表4

参考文献 32

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年龄	平均值	标准差
出生	20.0	-
<1.2月	52.0	9.0
1.2~3.6月	61.7	14.3
3.6~7.9月	71.7	13.9
7.9~12月	82.6	17.3
12~18月	91.5	17.8
18~24月	94.5	18.1
25~36月	104.4	19.9
3~4岁	111.2	18.5
5~6岁	114.1	18.6
7~8岁	111.3	18.3
9~10岁	110.0	21.6
11~12岁	116.4	18.9
13~15岁	117.2	16.1
16.2~34岁	112.0	13.0

方法	相对分子质量	优点	缺点
菊粉	5 200，不与血浆蛋白结合	金标准	价贵，在溶液中难以溶解和维持，供应有限
碘海醇	821，血浆蛋白结合率<2%	非放射性，敏感的分析条件下允许低剂量	肾小管可能再吸收或蛋白结合，低估GFR，使用低剂量时需要昂贵的化验，不能用于碘过敏患者，高剂量有肾毒性和过敏反应风险
同位素：¹²⁵I-碘钛酸盐(Iothalamate)	636	价廉，半衰期较长，可用于研究	可能有小管分泌，导致GFR高估，¹²⁵I放射性物质的存储、管理和处置的特殊要求，甲状腺可能摄取¹²⁵I，使用非放射性碘酸盐需要昂贵的化验，不能用于碘过敏患者
⁵¹Cr-EDTA	292，半衰期约2 h，不与血浆蛋白结合	在欧洲广泛使用	肾小管有再吸收，导致低估GFR，放射性物质的储存管理和处置要求
^99mTc-DTPA	393，半衰期约6 h	在美国广泛应用，使用新的钆分析，灵敏度高，易于分析	放射性物质的存储、管理和处置的特殊要求，^99mTc半衰期短，不适合研究性质，要求^99mTc标准化，^99mTc的解离和可部分与蛋白结合致GFR低估，使用钆作为示踪剂时需要注意可致肾纤维化

因素	肌酐	胱抑素C
肌肉量减少或截肢	++↓
年龄增加	++↑	+↓
性别（女）	+↓
种族非洲裔美国人(AA)	+↑
种族亚裔	+↓
肉摄入、补充肌酐药物（西咪替丁、甲氧苄氨嘧啶、非诺贝特）	+↑
肝纤维化/肝衰	+↓
甲状腺亢进或甲减	+↓/↑	+↑
糖皮质激素	+↓	+↑
炎症		+↑

儿童肾小球滤过率的临床应用

Clinical application of glomerular filtration rate in children

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