Transteorik modelning taxminiy glomerulyar filtratsiya tezligining pasayishini bashorat qiluvchi bosqichlari: retrospektiv kohort tadqiqoti

ANTRACT

Fon:Thetransnazariy model(TTM) bemorning ongiga ko'ra bir necha bosqichlardan iborat bo'lib, odamlarni sog'lom xatti-harakatlarning muhimligini tushunishga olib keladi, deb ishoniladi. Biz TTM bosqichlarining taxminiy glomerulyar filtratsiya tezligining (eGFR) pasayishi bilan bog'liqligini ko'rib chiqdik.

Usullar: Biz 2012-yil aprelidan 2016-yilning martigacha Kioto prefekturasida joylashgan Yaponiya sogʻliqni sugʻurtasi assotsiatsiyasining yillik tibbiy tekshiruv maʼlumotlari va tibbiy sugʻurta daʼvolari maʼlumotlaridan foydalandik. TTM oʻzgarishlar bosqichlari birinchi tibbiy koʻrikda soʻrovnomalardan olingan va oltita guruhga boʻlingan. Birlamchi natija birinchi tibbiy ko'rikdan eGFRning 30% dan ko'proq pasayishi sifatida aniqlandi. Biz ko'p o'zgaruvchan Cox proportsional xavf modelini yosh, jins,eGFR, tana massasi indeksi, qon bosimi, qon shakar,dislipidemiya, siydik kislotasi, siydik oqsili vabuyrak kasalliklarining mavjudligibirinchi tibbiy ko'rikda. Natijalar: Biz 239,755 xodimni tahlil qildik va o'rtacha kuzatuv 2,9 (standart og'ish, 1,2) yil edi. 1-bosqich guruhi bilan solishtirganda, 3-bosqich guruhida eGFR pasayish xavfi sezilarli darajada past edi (xavf darajasi [HR] 0.77; 95% ishonch oraligʻi [CI], 0.65 –0.91); 4-bosqich guruhi (HR 0.8{{20}}; 95% CI, 0.65–0.98); va 5-bosqich guruhi (HR 0.79; 95% CI, 0.66-0.95).

Xulosa:Tafakkurdan oldingi bosqich (1-bosqich) bilan solishtirganda, tayyorgarlik, harakat va parvarishlash bosqichlari (3, 4 va 5-bosqichlar) pastroq bo'lgan.eGFR pasayishi xavfi.

Kalit so‘zlar:transnazariy model; surunkali buyrak kasalligi; buyrak shikastlanishi; o'zgarish bosqichi; taxmin qilingan glomerulyar filtratsiya tezligining 30% dan ortiq pasayishi

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KIRISH

Surunkali buyrak kasalligi(CKD) ko'p yillar davomida global sog'liqni saqlash muammosi bo'lib kelmoqda va uning tarqalishi butun dunyo bo'ylab 500 million kishi orasida taxminan 10-15% ni tashkil etdi.1 KKHning rivojlanishi diabet, gipertenziya va tizimli immunitet buzilishlari kabi ko'plab patofizyologik xavflar tufayli yuzaga keladi.1 Yaqinda ovqatlanish va turmush tarzidagi o'zgarishlar buyrak funktsiyasiga ta'sir qilishi aniqlandi, shuning uchun buyrak kasalligi: Global natijalarni yaxshilash (KDIGO) yo'riqnomasi endi buni tavsiya qiladi.CKD bilan og'rigan bemorlarularning xatti-harakatlarini, shu jumladan chekish, sog'lom vaznlari va kundalik jismoniy faolligini kuzatishi va o'zgartirishi kerak.2 Darhaqiqat, hozirgi sigaret chekuvchi bilan solishtirganda o'tmishda chekuvchi bo'lish KKD rivojlanishi xavfining pasayishi bilan bog'liq ekanligi haqidagi dalillar3 xatti-harakatlarning o'zgarishi mumkinligini ko'rsatadi. kasallikning rivojlanishini sekinlashtiradi. Biroq, muammo shundaki, bunday sog'lom xatti-harakatlarni o'zgartirish klinik sharoitlarda oson ko'rinmaydi. So'nggi paytlarda ushbu muammoni hal qilish uchun psixoterapiyaning ba'zi integrativ nazariyalari rivojlandi. Xulq-atvorni o'zgartirishning transnazariy modeli (TTM) oddiy odamlarni vaqtinchalik o'lchovlarga ko'ra besh toifaga ajratadigan integral nazariyalardan biridir.4 Umuman olganda, odamlar oldindan tafakkurdan tafakkurga qadar besh bosqichdan o'tadi, so'ngra tayyorgarlik, so'ngra harakat. va ularning xatti-harakatlarini o'zgartirganda parvarishlash bosqichlari. Yaqinda o'tkazilgan tadqiqotlar shuni ko'rsatdiki, TTMga asoslangan aralashuv lipidlarni pasaytiruvchi yoki antihipertenziv dorilarga rioya qilishni yaxshilagan,5,6 va randomizatsiyalangan nazorat ostida o'tkazilgan tadqiqotda sog'lom ovqatlanish, jismoniy mashqlar va boshqa sog'lom xatti-harakatlarni rag'batlantirgan.7 Shunga qaramay, aniq mexanizmlarni tushunish muhimdir. qaysi xatti-harakatlar buyrak funktsiyasiga ta'sir qiladi. Birinchi qadam, har bir bosqich bilan bog'liqligini aniqlash bo'ladiCKD rivojlanishi. Bu erda biz Yaponiyaning salomatlik tekshiruvi ma'lumotlar bazasidan foydalanib, KKH rivojlanishining TTM bosqichlari bilan bog'liqligini tekshirdik.

USULLARI

Ma'lumotlar bazasi va maqsadli populyatsiyalar Biz Yaponiyaning Kioto prefekturasida joylashgan Yaponiya sog'liqni sug'urtasi assotsiatsiyasi tomonidan sug'urtalangan kompaniyalardagi ish beruvchilarning yillik tibbiy tekshiruv ma'lumotlari va tibbiy sug'urta da'volari ma'lumotlaridan foydalangan holda retrospektiv tahlil qildik. 35 yoshdan oshgan xodimlarni har yili tibbiy ko'rikdan o'tkazish, ular o'z huquqlarini yo'qotmaguncha (masalan, ish joyini o'zgartirmaguncha, boshqa hududga ko'chib o'tguncha yoki vafot etguncha) majburiydir.

Ishtirokchilarni kiritish va istisno qilish mezonlari Biz 35 yoshdan 75 yoshgacha bo'lgan va 2012 yilning aprelidan 2016 yilning martigacha ikki yoki undan ortiq tibbiy ko'rikdan o'tgan xodimlarni ishga qabul qildik. Birinchi tibbiy ko'rikda buyrak kasalligi yoki ma'lumotlar etishmayotgan shaxslarni hisobga olmadik. Har bir tibbiy ko'rikda so'rovnomalar olindi va ularda retseptlangan dorilar, sog'lom xatti-harakatlar va spirtli ichimliklarni iste'mol qilish haqida ma'lumotlar mavjud. Buyrak kasalligi da'volar ma'lumotlarida Kasalliklarning xalqaro tasnifi, N00-08, I70 va Q61 kabi 10-revizion kodlari bilan aniqlangan.

Baseline variables TTM stages of a change obtained from questionnaires at the first health checkup were categorized into six groups by the question: "Do you intend to improve your lifestyle habits of diet and exercise?: do not intend to take action in the foreseeable future, regarded as stage 1; intend to change in the next 6 months, regarded as stage 2; intend to take action in the immediate future until the next month, regarded as stage 3; made specific overt modifications in their lifestyles within the past 6 months, regarded as stage 4; a prevent relapse, but they did not apply change processes as frequently as people in action, regarded as stage 5; no answer to the question (missing data), regarded as "no concern". The lifestyle behavior changes, including smoking cessation, undertaking physical activity, and achieving a healthy weight 1 year after the first health check-up, were obtained from questionnaires on the next health check-up: Those who are "quitting smoking" mean those who answered "Yes" in the previous year and answered "No" in the present year to the question, "Are you a heavy smoker? (A heavy smoker refers to those who have smoked a total of over 100 cigarettes or have smoked for 6 months and have been smoking during the past month.)". Those who are "Undertaking physical activity" mean those who answered "No" in the previous year and answered "Yes" in the present year to the question, "Are you in a habit of doing exercise to sweat lightly for over 30 minutes a time, two times weekly, for over a year?". "Decrease in the amount of drinking" is determined according to the question, "How much do you drink per day?". "Decrease in the frequency of drinking" means an answer to the question "How often do you drink? (sake, shochu, beer, wine, whisky, or brandy, etc)". The contents of the questionnaires were created by reference to "Standard medical checkup and health guidance programs" by the Japanese government: Ministry of Health, Labor, and Welfare.8 The covariates were classified into groups as follows: four groups based on age (35–45, 46–55, 56–65, and 66 or more years); four groups based on body mass index (BMI; thin: ≤18.5 kg=m2 , normal: 18.5–25 kg=m2 , pre-obesity: 25–30 kg=m2 , and obesity: >30 kg=m2 ) according to the World Health Organization; five groups based on eGFR (≤15, 30–15, 45–30, 60–45, and >60 ml=min=1,73 m2 ); uchta guruhga asoslangan siydik oqsili (ko'rsatkichlar yordamida: musbat ({5}} dan katta yoki teng), iz (±) va salbiy), qorin atrofi (agar erkak 85 sm dan katta yoki unga teng bo'lsa, ayol dan katta yoki teng). 90 sm gacha); qon bosimiga asoslangan besh guruh (sistolik qon bosimi [SBP] 180 mm simob ustuni yoki diastolik qon bosimi [DBP] 110 mm Hg dan katta yoki unga teng, SBP 160 mm Hg yoki DBP dan katta yoki teng Dorisiz 100 mm Hg dan katta yoki unga teng, SBP 140 mm Hg dan katta yoki teng yoki DBP Dorisiz 90 mm Hg dan katta yoki teng, giyohvand moddalarsiz va dorilar bilan normal); va dislipidemiyaga asoslangan to'rtta guruh (triglitseridlar 150 mg=dL dan yuqori yoki unga teng yoki yuqori zichlikdagi lipoprotein xolesterin<40 mg=dL was defined to be abnormal with hypolipidemic drugs, abnormality without hypolipidemic drugs, normal with hypolipidemic drugs, normal without hypolipidemic drugs), diabetes (fasting blood sugar ≥110 mg=dL or hemoglobin A1c ≥5.6% was defined to be as abnormality with antidiabetic drugs, abnormality without antidiabetic drugs, normal with antidiabetic drugs, normal without antidiabetic drugs), and hyperuricemia (defined uric acid ≥8 mg=dL without drugs or with use of anti-hyperuricemias). The information for each medication use was extracted from questionnaires.

Statistik tahlil

The primary outcome for survival analysis was defined as a decrease of 30% or more in eGFR.9 The eGFR was calculated by the equation used by the Japanese Society of Nephrology.10 Patients were followed until the outcome or censored. The Cox proportional-hazards model was used for time-to-event analyses to estimate the hazard ratios (HRs); a 95% confidence interval (CI) was used for the primary outcome. Follow-up period data for patients were censored on the date of the last health checkup. The analysis used two types of models: model 1 (without medication factors), adjusted for age, sex, BMI, abdominal circumference, eGFR, and urinary protein; and model 2 (with medication factors), adjusted for age, sex, BMI, abdominal circumference, eGFR, urinary protein, blood pressure, blood sugar, dyslipidemia, and uric acid. All the covariates were detected at the first health checkup. Schoenfeld residuals were used to check the proportional hazards assumption. A two-sided significance level of 0.05 was used, and all analyses were conducted using R version 3.4.1 (R Foundation for Statistical Computing, Vienna, Austria). Subgroup analyses were performed for the model 2 condition, where the analysis population was stratified by employees 1) whose eGFR categorized as >60, 60–45 yoki 45 ml =min=1 dan kam yoki unga teng, 73 m2 va 2) qandli diabet tufayli kasalxonaga bormagan (qon shakarini kamaytiradigan dori yoki insulin in'ektsiyasi yo'q) , va 3) yapon metabolik sindromi uchun 1 yoki undan ortiq mezonga javob berganlar.11 Sezuvchanlik tahlillari 2-model holati uchun ham o‘tkazildi, bunda biz tahlil populyatsiyasi 1) 60 va undan katta yoshdagi xodimlarni yoki 2) har qanday kasallikni qabul qilgan xodimlarni chiqarib tashladik. gipertoniya, diabet yoki dislipidemiya uchun dori. Sobiq xodimlar bundan mustasno edi, chunki Yaponiyada pensiya 60-65 yoshda sodir bo'lishi ehtimoli ko'proq, bu sog'lom ishchilarning noto'g'riligiga olib kelishi mumkin va biz kuzatuvda yo'qolgan xodimlarning ta'sirini minimallashtirdik.

NATIJALAR

Jami 253 673 nafar xodim ro‘yxatga olindi va qo‘shilish mezonlarini bajardi; 12 593 (4,9%) ma'lumotlar etishmayotganligi va 1 392 tasi buyrak kasalliklarining tarqalishi sababli chiqarib tashlandi. Qolgan 239 755 nafar xodimni tahlil qildik (1-rasm). Kuzatuv oxiriga kelib, eGFR 30% yoki undan ko‘proq pasaygan 1836 kishi (0,8%), o‘rtacha kuzatuv esa 2,9 (standart og‘ish, 1,2) ni tashkil etdi. yillar. Har bir bosqichning xarakteristikalari 1-jadvalda ko'rsatilgan. 5-bosqich guruhida qon zardobidagi kreatinin darajasi yuqori va retsept bo'yicha beriladigan dori-darmonlar, shu jumladan diabet va dislipidemiya uchun ham ko'proq bo'lgan. Birinchi tibbiy ko'rikdan so'ng 1 yil ichida jismoniy faollikning o'zgarishi 3-5 bosqichlarda 1-2 bosqichlarga qaraganda yuqori bo'ladi. Xususan, 3-bosqichda jismoniy faollik ulushi 8.0%; 4-bosqichda 12,0%; va 5-bosqichda 8,6%, 1-bosqichda 5,3%; 2-bosqichda 5,2%.

Shakl 1. Kioto prefekturasidagi Yaponiya sog'liqni sug'urtalash assotsiatsiyasidan tadqiqot ishtirokchilarini tanlash uchun oqim sxemasi

Compared with the stage 1 group, the risk of decreasing renal function was significantly lower in the stage 3 group (HR 0.77; 95% CI, 0.65–0.91); in the stage 4 group (HR 0.80; 95% CI, 0.65–0.98); and the stage 5 group (HR 0.79; 95% CI, 0.66– 0.95), after adjusting for age, sex, eGFR, body mass index, blood pressure, blood sugar, dyslipidemia, uric acid, urinary protein (Table 2). The forest plots of the HRs of other covariates are shown in Figure 2, which shows that urinary protein, diabetes, blood pressure, age, and lower eGFR were associated with decreasing renal function. The major results of the subgroup analysis are shown in Figure 3. When we included 226,667 employees whose eGFR was >60 mL=min=1,73 m2, buyraklar faoliyatining pasayishi xavfi darajasi 0,95 (95% CI, 0,83- 1.09) 2-bosqich guruhida, 0.76 (95% CI, 0.63–0.92) 3-bosqich guruhida, { 4-bosqich guruhida {29}}.83 (95% CI, 0.67–1.04) va 0.84 (95% CI, {{54) }}.69–1.03) 5-bosqich guruhida, 1-bosqich guruhi bilan solishtirganda. Biz eGFR darajasi 45–60 ml=min= 1,73 m2 bo'lgan 12,{62}}49 nafar xodimni kiritganimizda, buyraklar faoliyatining pasayishining xavf nisbati {{67} edi. }},78 (95% CI, {{70}},49-1,26) 2-bosqich guruhida, 0,81 (95% CI, 0.45- 1.48) 3-bosqich guruhida, 0.19 (95% CI, 0.{{1{{110}}5}}6-0.61) 4-bosqichda guruh va 5-bosqich guruhida 1-bosqich guruhiga nisbatan 0,65 (95% CI, 0,34-1,22). Biz eGFR 45 ml=min=1,73 m2 dan kam yoki unga teng bo'lgan 1039 nafar xodimni kiritganimizda, buyraklar faoliyatining pasayishi xavfi darajasi 0,98 (95% CI, 0,60–1,58) edi. 2-bosqich guruhi, 3-bosqich guruhida 0,87 (95% CI, 0,50-1,52), 4-bosqich guruhida 1,19 (95% CI, 0,63-2,23) va bosqichda 0,70 (95% CI, 0,40-1,23) 5 guruh, 1-bosqich guruhi bilan solishtirganda. Boshqa kichik guruhlarda ballni baholash tendentsiyasi tubdan o'zgarmadi.

Sezuvchanlik tahlili ham xuddi shunday xavf nisbatlarini ko'rsatdi. Biz 60 va undan katta yoshdagi xodimlarni chiqarib tashlaganimizda, natijalar bosqichda 0.95 (95% CI, 0.82–1.09) edi. 2 guruh, 0.77 (95% CI, 0.63–{{20}}.94) 3-bosqich guruhida, 0.83 ( 95% CI, {{30}},65–1.05) 4-bosqich guruhida, 0,75 (95% CI, 0. 5-bosqich guruhida 60–0.95) va {{6{62}}}}.99 (95% CI, 0.84–1.18) noma'lum bosqich guruhi, 1-bosqich guruhi bilan solishtirganda. Gipertenziya, diabet yoki dislipidemiya uchun biron bir dori qabul qilgan xodimlarni hisobga olmaganda, natijalar 1.07 (95% CI, {{7{{0}},91-1,25) edi. 2-bosqich guruhi, 3-bosqich guruhida 0,79 (95% CI, 0,63–1.00), 4-bosqich guruhida 0,68 (95% CI, 0,50–0,93), 0,75 (95% CI, 0,56–). 0,99) 5-bosqich guruhida va noma'lum bosqich guruhida 1,14 (95% CI, 0,94-1,37) 1-bosqich guruhiga nisbatan.