临床儿科杂志 ›› 2022, Vol. 40 ›› Issue (12): 886-893.doi: 10.12372/jcp.2022.22e1222
高春林
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:
GAO Chunlin
Received:
2022-09-13
Published:
2022-12-15
Online:
2022-12-06
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。
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.
表1
不同年龄正常儿童51Cr-EDTA测定的GFR[2-3] (mL?min-1?1.73 m-2)"
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 |
表2
mGFR测定方法及特点"
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 |
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 |
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