本文選題：IgA腎病　切入點(diǎn)：終末期腎病　出處：《上海交通大學(xué)》2015年博士論文　論文類型：學(xué)位論文

【摘要】：目的:研究日本Goto、日本Utsunomiya、法國(guó)Berthoux和我國(guó)瑞金模型對(duì)IgA腎病進(jìn)展至ESRD風(fēng)險(xiǎn)的預(yù)測(cè)能力,并初步建立符合我國(guó)IgAN特點(diǎn)的ESRD風(fēng)險(xiǎn)預(yù)測(cè)模型。方法:選取上海交通大學(xué)醫(yī)學(xué)院附屬新華醫(yī)院1998年6月至2014年6月間IgAN確診患者535例,完善基線資料及隨訪信息采集。其中356例結(jié)局明確的患者納入模型驗(yàn)證組,分別評(píng)價(jià)四種模型對(duì)驗(yàn)證組患者ESRD發(fā)生風(fēng)險(xiǎn)的預(yù)測(cè)能力。535例患者全部納入模型建立組,通過(guò)單因素及多因素危險(xiǎn)分析篩選獨(dú)立危險(xiǎn)因素,利用Kaplan-Meier法和Cox比例風(fēng)險(xiǎn)模型建立新的風(fēng)險(xiǎn)預(yù)測(cè)模型。以分辨力及校準(zhǔn)度評(píng)價(jià)各模型的預(yù)測(cè)能力。以受試者工作特征曲線下面積診斷模型分辨力,AUC0.9表示模型分辨力較高,p0.05表示差異有統(tǒng)計(jì)學(xué)意義。采用Hosmer-Lemeshow檢驗(yàn)對(duì)各模型進(jìn)行擬合優(yōu)度檢驗(yàn),p0.05表示模型校準(zhǔn)度較好。結(jié)果:驗(yàn)證組356例患者中有38例進(jìn)展至ESRD。Goto模型對(duì)2年、5年內(nèi)ESRD發(fā)生風(fēng)險(xiǎn)預(yù)測(cè)的分辨力較高(2年AUC=0.958,5年auc=0.950,p0.05),10年風(fēng)險(xiǎn)的分辨力稍低(auc=0.876,p0.05)。utsunomiya模型對(duì)2年、5年、10年風(fēng)險(xiǎn)的分辨力總體較高(2年auc=0.923,5年auc=0.933,10年auc=0.915,p0.05)。berthoux模型的分辨力均較低(2年auc=0.819,5年auc=0.808,10年auc=0.780,p0.05)。瑞金模型對(duì)2年、5年、10年風(fēng)險(xiǎn)預(yù)測(cè)的分辨力均較高(2年auc=0.946,5年auc=0.939,10年auc=0.931,p0.05)。四種模型的校準(zhǔn)度均較好(p0.05)。模型建立組535例患者中有40例進(jìn)展至esrd,151例失訪。單因素分析發(fā)現(xiàn),男性、年齡增長(zhǎng)、egfr下降、初始血肌酐升高、收縮壓升高、舒張壓升高、尿蛋白排泄量升高、貧血、低白蛋白血癥、高尿酸血癥、總膽紅素降低、血清c3降低、嚴(yán)重腎小管萎縮或間質(zhì)纖維化、新月體形成比例增高、腎小球球性硬化比例增高等15項(xiàng)指標(biāo)是igan進(jìn)展至esrd的危險(xiǎn)因素。多因素cox回歸分析提示,腎小球球性硬化比例(β=2.204,hr=9.062,p=0.004)、細(xì)胞性新月體及纖維細(xì)胞性新月體形成比例(β=2.004,hr=7.422,p=0.039)和egfr(β=-0.069,hr=0.934,p0.001)是我國(guó)igan患者進(jìn)展至esrd的獨(dú)立危險(xiǎn)因素。新模型預(yù)測(cè)的分辨力高于上述四種模型(2年auc=0.964,5年auc=0.965,10年auc=0.959,p0.001),校準(zhǔn)度亦較高(?2=9.905,p=0.272)。結(jié)論:goto模型2年、5年風(fēng)險(xiǎn)預(yù)測(cè)能力優(yōu)于其他三種模型,瑞金模型10年風(fēng)險(xiǎn)預(yù)測(cè)能力最佳,Utsunomiya模型預(yù)測(cè)能力總體較好,較上述兩種模型稍差,Berthoux模型預(yù)測(cè)能力最差。腎小球球性硬化比例、細(xì)胞性新月體及纖維細(xì)胞性新月體形成比例和eGFR是我國(guó)IgAN患者進(jìn)展至ESRD的獨(dú)立危險(xiǎn)因素。新模型對(duì)2年、5年、10年內(nèi)ESRD發(fā)生風(fēng)險(xiǎn)具有較高分辨力和校準(zhǔn)度,新模型危險(xiǎn)分層可實(shí)現(xiàn)對(duì)患者進(jìn)行合理評(píng)估及分層管理,總體預(yù)測(cè)能力較佳。
[Abstract]:Objective: to study the predictive ability of Goto, Utsunomiya, Berthoux and Ruijin models in China for predicting the risk of progression of IgA nephropathy to ESRD. Methods: 535 patients diagnosed with IgAN from June 1998 to June 2014 in Xinhua Hospital affiliated to Shanghai Jiaotong University Medical College were selected. To improve baseline data and follow up information collection, 356 patients with definite outcome were included in the model validation group, and the predictive ability of four models to predict the risk of ESRD in the validation group. 535 patients were all included in the model building group. Independent risk factors were screened by univariate and multivariate risk analysis. A new risk prediction model was established by using Kaplan-Meier method and Cox proportional risk model. The predictive ability of each model was evaluated by resolution and calibration degree. The model resolution was expressed by the area diagnosis model resolution under the operating characteristic curve of subjects and AUC0.9. Hosmer-Lemeshow test was used to test the goodness of fit for each model. Results: 38 out of 356 patients in the validation group had advanced to ESRD.Goto model within 2 and 5 years. The resolution of the genetic risk prediction was higher (2 years AUCX 0.958, 5 years aucmated 0.950 p0.05a, 10 year risk resolution was slightly lower than that of 10 years risk model 0.876 p0.05U. Utsunomiya model for 2 years, 5 years, 10 years risk resolution for 2 years, 5 years auction 0.923, 5 years auc0. 933, 10 years auc0. 915 p0.05n.berthoux model were lower (2 years auc0. 0. 808, 0. 808 in 5 years, 0. 780 p 0. 05. 0. 05%.) the resolution of 10 years risk was higher than that of 10 years of auction (0. 923, 0. 933, 0. 915, 0. 808, 0. 808, 0. 780 p 0. 05) respectively. The model had higher resolution for 2, 5 and 10 years risk prediction (2 years aucnus 0.946, 5 year aucmor 0.939, 10 year auction 0.931 p0.05). The calibration degree of the four models was better. 40 of 535 patients in the model-building group had advanced to ESR 151 cases. Univariate analysis showed that, In males, age increased, initial serum creatinine increased, systolic blood pressure increased, diastolic blood pressure increased, urinary protein excretion increased, anemia, hypoalbuminemia, hyperuricemia, total bilirubin decreased, serum c3 decreased. Fifteen indexes, such as severe tubular atrophy or interstitial fibrosis, increased crescent shape and glomerular sclerosis, were the risk factors for the progression of igan to esrd. The ratio of glomerular glomerulosclerosis (尾 -2.204), the ratio of cellular crescents to fibrocytic crescents (尾 2.004 ~ 7.422p0. 039) and egfr- (尾 -0.069? HR0.934 / p0.001) are independent risk factors for the progression to esrd in igan patients in China. The resolution predicted by the new model is higher than that of the four models (2 years auc0.964 / 5). A year of auction 0.965, a 10-year auction of 0.959 p0.001g, and a higher calibration degree? 2 / 9.905 / 0.272. Conclusion the 5 year risk forecasting ability of the two year model is better than that of the other three models, and the best risk forecasting ability of Ruijin model is 10 years. The Utsunomiya model has a better forecasting ability. The prediction ability of Berthoux model was worse than that of the above two models. The proportion of cellular crescents and fibrocytic crescents and eGFR are independent risk factors for the progression to ESRD in IgAN patients in China. The new model has high resolution and calibration for the risk of ESRD in 2, 5 and 10 years. The new model can realize reasonable assessment and management of patients with risk stratification, and the overall predictive ability is better.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R692.31

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