<BFF8C0FA D C3D6C1D8BCAE2E687770>

Size: px

Start display at page:

Download "<BFF8C0FA D C3D6C1D8BCAE2E687770>"

재돌 조
5 years ago
Views:

1 대한내과학회지 : 제 78 권제 5 호 2010 만성신장질환이급성허혈성뇌졸중의예후에미치는영향 전남대학교의과대학내과학교실 최준석 김하연 옥찬영 김민지 김창성 오슬현이형철 박정우 배은희 마성권 김남호 김수완 Impact of renal dysfunction on clinical outcomes of acute ischemic stroke Joon Seok Choi, M.D., Ha Yeon Kim, M.D., Chan Young Oak, M.D., Min Jee Kim, M.D., Chang Sung Kim, M.D. Seul Hyun Oh, M.D., Hyung Chul Lee, M.D., Jeong Woo Park, M.D., Eun Hui Bae, M.D., Seong Kwon Ma, M.D. Nam Ho Kim, M.D., and Soo Wan Kim, M.D. Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea Background/Aims: Chronic kidney disease is recognized as an independent risk factor for coronary artery disease. It is unknown whether renal function predicts clinical outcomes of acute ischemic stroke. The present study was aimed at examining the correlation between the degree of renal dysfunction and stroke outcome. Methods: Our retrospective study included 282 consecutive patients hospitalized due to acute ischemic stroke. Renal function was assessed by the estimated Glomerular filtration rate (GFR), using two methods: Cockcroft-Gault equation and Modification of Diet in Renal Disease (MDRD) equation. Each of the estimated GFRs were categorized into three groups (Group I: ml/min/1.73 m 2, Group II: ml/min/1.73 m 2, Group III: ml/min/1.73 m 2 ). From collected patient databases, we compared mortality and rate of hospitalization to GFR at 1 month and 12 months follow up. Results: Our study found that, based on the GFR, the 1 year mortality, using the Cockcroft-Gault equation, was 6.0% in group I, 20.3% in group II and 21.1% in group III and, using the MDRD equation, 9.1%, 12.5% and 37.5%, respectively. Patients with lower GFRs exhibited an increased odds ratio for 1 year mortality when estimated by the Cockcroft-Gault equation: 3.97 (1.7~9.2, 95% CI) in group II and 4.16 (1.2~14.5, 95% CI) in group III. Based on the MDRD equation, patients with lower GFRs also exhibited an increased odds ratio for 1-year mortality: 1.43 (0.5~4.4, 95% CI) in group II and 6.00 (1.3~26.8, 95% CI) in group III. The adjusted odds ratio for 1-year mortality also increased based on our analysis using either equation. Conclusions: Decline of GFR and severity of chronic kidney disease are associated with poor clinical outcomes of acute ischemic stroke. (Korean J Med 78: , 2010) Key Words: Chronic kidney disease; Acute ischemic stroke; Mortality Received: Accepted: Correspondence to Soo Wan Kim, M.D., Department of Internal Medicine, Chonnam National University Medical School, 671 Jaebongro, Dong-gu, Gwangju , Korea skimw@chonnam.ac.kr

2 - Joon Seok Choi, et al. Impact of renal dysfunction in acute ischemic stroke - 서론만성신장질환 (chronic kidney disease) 은높은사망률과심혈관계질환과같은합병증을유발하는질환으로그발생률과유병률이꾸준히증가하고있어공공의료의주요한문제점으로대두되고있다 1-3). 만성신장질환은세계적으로 10 명중 1명이갖고있다고알려져있으며미국은 11% 4), 우리나라의경우는대도시에거주하는 35세이상의성인에서 13.8% 의유병률을나타내는것으로알려져있다 5). 만성신장질환과심혈관계질환의발생률에대해서는여러연구들을통해그관련성이입증되었다. 만성신부전환자에서심혈관계질환에의한사망률이일반인에비해 10~20배높은사망률을나타내고있으며, 가벼운정도의신기능감소라도심혈관계질환의이환율과사망률을증가시킬수있다 6-9). 급성관상동맥증후군에서사구체여과율의감소가예후에영향을미치는중요한인자임이규명되었으나급성허혈성뇌졸중에서의신장기능감소에따른예후와의상관성에대해서는상대적으로연구가부족한편이다 10-13). 또한한국인에서신장기능의감소가급성허혈성뇌졸중의예후에미치는영향에대해서는아직까지연구가되어있지않다. 급성관상동맥증후군과급성허혈성뇌졸중의위험인자는서로다를수있기에만성신장질환과급성허혈성뇌졸중의상관관계에대해연구하는것이중요하다하겠다 10). 이에저자들은전남대학교병원에내원한급성허혈성뇌졸중환자에서두가지의공식을이용하여사구체여과율을측정하여뇌졸중환자에서의만성신장질환의중증도에따른뇌졸중의예후에대해조사를시행하였다. 대상및방법 1. 대상환자 2006년 1월부터 2006년 12월까지전남대학교병원에내원한환자중급성허혈성뇌졸중으로진단받은환자 282예 (63.8±11.7 세, 남성 62.8%) 를대상으로후향적연구를시행하였다. 2. 방법환자들의내원당시나이, 성별, 체질량지수, 심혈관계질환의위험인자 ( 고혈압, 당뇨병, 흡연, 고지혈증, 가족력 ), 신체검사기록을참조하였다. 내원당일혈액을채취하여헤모글로빈, 콜레스테롤, 혈장 creatinine 농도는내원당일채취한자료를참조하였다. 뇌졸중의진단은뇌 CT나 MRI 결과 에의해진단되었으며중증도는 National Institute of Health Stroke Scale (NHISS) 14) 을사용하여평가하였다. 1개월과 12 개월후에입원및외래추적관찰을통하여생존여부와요양기관누적재원여부를확인하였으며추적관찰이되지않았던환자들에게는전화인터뷰를통해자료를수집하였다. 사구체여과율은내원시얻어지는자료를참조하여 Cockcroft-Gault 공식 15) 과 Modification of Diet in Renal Disease (MDRD) 공식 16) 을이용하여측정하였으며사구체여과율에따라 3군으로세분하여분석을시행하였다 (I군: ml/min/ 1.73 m 2, II군 : ml/min/1.73 m 2, III군 : ml/min/ 1.73 m 2 ). 말기신부전환자 ( 사구체여과율 <15 ml/min/1.73 m 2 또는신대체요법치료중인환자 ) 의경우뇌혈관의동맥경화가진행되어급성뇌졸중의유병률과사망률을증가시키는독립적인자임이잘알려져있다 17,18). 따라서본연구에서는가벼운정도의신기능감소라도급성뇌졸중환자의예후에미치는영향을알아보기위하여말기신부전환자들은제외하였다. 3. 용어정의사구체여과율은두가지공식을이용하여측정하였다. (1) Cockcroft-Gault formula: [(140-age) weight (kg)]/[serum creatinine (mg/dl) 72] ( 0.85, if the subject is female) (2) abbreviated Modification of Diet in Renal Disease (MDRD) formula: 186 (Scr) (age) ( 0.742, if the subject is female). The National Kidney Foundation in the Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) 4) 에의한정의에따라사구체여과율 60 ml/min/1.73 m 2 미만을만성신부전으로정의하였으며혈장 cretinime 농도의추적검사상 3개월이내에사구체여과율의정상화가이루어진경우는급성신기능손상으로분석에서제외하였다. 4. 통계학적분석통계학적분석을위해연속변수는평균 ± 표준편차 (mean±sd) 로표시하였다. 통계학적유의성검정은윈도우용통계프로그램 (SPSS Window version 17.0) 을이용하였으며, 대상비교는 one-way ANOVA test와 Chi-square test 및 Fisher's exact test방법으로검정하였다. 다변량회귀분석 (multiple logistic regression analysis) 을통하여사구체여과율이사망률, 요양기관재원율및뇌졸중의중증도에미치는차이비율 (odds ratio) 을평가하였다. Kaplan-Meier 생존곡선으로각군에서의 1년생존율을표현하였다. p 값이 0.05 미만인경우유의성

3 - 대한내과학회지 : 제 78 권제 5 호통권제 597 호 이있는것으로판정하였다. 결과 1. 임상적특징 2006년 1월부터 2006년 12월까지전남대학교병원에내원한환자중급성허혈성뇌졸중으로진단받은환자 282명 (63.84±11.7세, 남성 62.8%) 이었다. 평균혈장 creatinine의농도는 0.93±11.74 mg/dl 이었으며 Cockcroft-Gault 공식에의한평균사구체여과율은 74.2±22.8 ml/min/1.73 m 2, MDRD 공식에의한평균사구체여과율은 85.5±24.4 ml/min/1.73 m 2 였다. 사구체여과율 60 ml/min/1.73 m 2 미만인만성신부전은 Cockcroft-Gault 공식의사구체여과율에서 83명 (29.4%), MDRD 공식의사구체여과율에서 40명 (14.2%) 으로공식에따라유의한차이를보였다. 각공식에따른사구체여과율의분포는그림 1에표시되었다. 사구체여과율에따라세군 (I 군 : ml/min/1.73 m 2, II 군 : ml/min/1.73 m 2, III 군 : ml/min/1.73 m 2 ) 으로세분하여만성신장질환의중증도를분류하였다. Cockcroft-Gault 공식의사구체여과율을사용한각군의특성은표 1에요약되어있다. 만성신부전에서고령이며체질량지수가낮은 경향을보였으며심근경색과거력과악성종양의빈도가많았다. 뇌졸중의중증도를평가하는 NHISS가사구체여과율이낮은군일수록증가되는양상을보였다. 당뇨, 고지혈증, 협심증등은세군에서유의한차이를보이지않았으며고혈압, 빈혈, 심방세동, 뇌졸중의과거력등이사구체여과율이낮은군에서많은빈도를보였으나통계적인의의는없었다. 2. 사망률과요양기관재원율의 1개월및 1년후추적관찰비교사구체여과율이낮은군에서 1개월과 1년후사망률및요양기관재원율이유의하게높았다 ( 표 2). Cockcroft-Gault 공식으로측정한사구체여과율이낮은군일수록 1년사망률이유의하게증가됨을관찰할수있었으며 [1년사망률 : I 군 (6.0%) vs. II군 (20.3%) vs. III군 (21.1%)], MDRD 공식으로측정한사구체여과율도낮은군에서 1년사망률이증가되었다 [1년사망률 : I군 (9.1%) vs. II군 (12.5%) vs. III군 (37.5%)]. 양공식을사용한군모두에서사구체여과율이낮은군일수록 1개월및 1년후사망률과요양기관재원율이유의하게증가됨이관찰되었다. 양공식을사용한각군에서의생존율을 Kaplan-Meier 생존곡선을이용하여분석하였다 ( 그림 2). 사구체여과율을측정하는공식의종류에관계없이사구 A B C Figure 1. Distribution of estimated GFR; (A) the Cockcroft-Gault equation, (B) MDRD equation, and (C) scatter plot of the Cockcroft-Gault and MDRD equation

4 - 최준석외 11 인. 급성허혈성뇌졸중에서신장기능의영향 - Table 1. Baseline characteristics by Cockcroft-Gault estimated GFR Cockcroft-Gault estimated GFR (ml/min/1.73 m 2 ) (n=199) (n=64) (n=19) p-value Age, yr 60.49± ± ±12.49 <0.01 Female, % Hypertension, % Diabetes, % Dyslipidemia, % Anemia, % Smoker, % Angina, % Prior myocardial infarction, % Prior stroke, % Atrial fibrillation, % Congestive heart failure, % Valvular heart disease, % Peripheral vessel disease, % Cancer, % BMI 24.27± ± ±2.03 <0.01 NHISS 6.07± ± ±5.47 <0.01 GFR, glomerular filtration rate; BMI, body mass index; NHISS, National Institute of Health Stroke Scale. Table 2. Clinical outcome by estimated GFR by the Cockcroft-Gault and MDRD equations Cockcroft-Gault estimated GFR ( ml/min/1.73 m 2 ) MDRD estimated GFR ( ml/min/1.73 m 2 ) ( n=199) ( n=64) ( n=19) p-value ( n=242) ( n=32) (n=8) p-value At 1 month Death, % < Death or nursing facility, % < <0.01 At 1 year Death, % < Death or nursing facility, % < <0.01 A (N=19 9) (N=6 4) B (N=19 9) (N=6 4) Figure 2. Kaplan-Meier estimates for cumulative 1-year survival function for all-cause mortality according to categories for GFR: (A) used Cockcroft-Gault equation (p-value=<0.01) and (B) used MDRD equation (p-value=0.01).

5 - The Korean Journal of Medicine: Vol. 78, No. 5, 체여과율이낮은군일수록사망률의증가가관찰되었다. 3. Multiple logistic regression analysis 를통한 odds ratio 평가 사구체여과율이낮은군일수록사망률및요양기관재원률에대한 odds ratio 가높았다 ( 표 3). Cockcroft-Gault 공식을사용하였을때 I 군에비해 II 군, III 군에서 1년후사망률에대한 odds ratio 의증가를관찰할수있었으며 [II 군 : 3.97 (1.7~9.2, 95% CI) vs. III 군 : 4.16 (1.2~14.5, 95% CI)] 1개월후사망률에대한 odds ratio 또한 II 군, III 군에서증가를관찰하였다 [II 군 : 3.33 (1.0~10.7, 95% CI) vs. III 군 : 6.03 (1.4~26.4, 95% CI)]. 요양기관재원률에서도 1개월후와 1년 후사구체여과율감소에따른 odds ratio 증가를관찰할수있었다. MDRD 공식을사용한군에서도 1년후사망률에대한 odds ratio 의증가를관찰할수있었으며 [II 군 : 1.43 (0.5~4.4, 95% CI) vs. III 군 : 6.00 (1.3~26.8, 95% CI)] 1개월후사망률에대해서도사구체여과율의감소에따른 odds ratio의증가를관찰하였다 [II 군 : 2.40 (0.6~9.2, 95% CI) vs. III 군 : 7.73 (1.4~43.2, 95% CI)]. 요양기관재원률에서도사구체여과율의감소에따른 odds ratio 의증가를관찰할수있었다. 급성허혈성뇌졸중의예후에영향을미칠수있는인자들인나이, 성별, 흡연력, 빈혈, 고혈압, 당뇨, 고지혈증및심혈관계질환들을교정한후 adjusted odds ratio 를산출하였다. Cockcroft-Gault 공식을사용시사구체여과율이감소할수록 Table 3. Logistic regression models for prediction of outcome by estimated GFR by the Cockcroft-Gault and MDRD equations Odds ratio (95% CI) Cockcroft-Gault estimated GFR ( ml/min/1.73 m 2 ) MDRD estimated GFR ( ml/min/1.73 m 2 ) (n=199) (n=64) (n=19) (n=242) ( n=32) ( n=8) At 1 month Death, % (1.0~10.7) 6.03 (1.4~26.4) (0.6~9.2) 7.73 (1.4~43.2) Death or nursing facility, % (2.0~6.5) (5.1~297.6) (1.9~9.7) At 1 year Death, % (1.7~9.2) 4.16 (1.2~14.5) (0.5~4.4) 6.00 (1.3~26.8) Death or nursing facility, % (1.9~6.7) (4.0~31.9) (1.3~6.1) 6.09 (1.4~26.3) Adjusted odds ratio (95% CI) Cockcroft-Gault estimated GFR ( ml/min/1.73 m 2 ) MDRD estimated GFR ( ml/min/1.73 m 2 ) ( n=199) (n=64) At 1 month Death, % (0.6~14.4) Death or nursing facility, % At 1 year (1.8~7.7) Death, % (0.9~6.9) Death or nursing facility, % (1.2~5.0) (n=19) 8.36 (1.0~67.4) (4.5~333.3) 2.77 (0.6~12.9) 9.03 (2.8~29.3) (n=242) (n=32) (0.8~39.1) (1.6~9.5) (0.3~4.6) (1.1~6.0) (n=8) (2.6~692.3) (0.9~60.0) 6.59 (1.2~33.3) * Adjusted for age, gender, anemia, hypertension, diabetes, dyslipidemia, smoker, angina pectoris, prior myocardial infarction, prior stroke, atrial fibrillation, congestive heart failure, valvular heart disease, peripheral vessel disease, malignancy.

6 - Joon Seok Choi, et al. Impact of renal dysfunction in acute ischemic stroke - 1년후사망률에대한 adjusted odds ratio의증가를관찰할수있었으며 [II군: 2.47 (0.9~6.9, 95% CI) vs. III군 : 2.77 (0.6~12.9, 95% CI)] 1개월후사망률에대한 adjusted odds ratio 또한 II 군, III군에서증가를관찰하였다 [II군: 2.86 (0.6~14.4, 95% CI) vs. III군 : 8.36 (1.0~67.4, 95% CI)]. 요양기관재원율에서도의미있는신뢰구간을나타내는 odds ratio 증가를관찰할수있었다. MDRD 공식을사용한군에서도 1년후와 1개월후사망률에대한 adjusted odds ratio 를관찰할수있었으며의의있는신뢰구간은확보하지못하였다 [1년사망률 ; II군 : 1.29 (0.3~4.6, 95% CI) vs. III군 : 7.47 (0.9~60.0, 95% CI), 1개월사망률 ; II군 : 5.50 (0.8~39.1, 95% CI) vs. III 군 : (2.6~692.3, 95% CI)]. 요양기관재원율에대해서는 odds ratio 를산출하지못하거나의의있는신뢰도를보이지않는군들이존재하였으나 odds ratio 의증가경향을확인하였다. 고찰사구체여과율의감소는심혈관질환의예후에영향을미치는중요한인자임이규명되었으나주로급성관상동맥증후군에서의그영향에대해서연구가이루어져있다 6-9). 본연구는상대적으로연구가부족한급성뇌졸중에서신장기능감소에따른예후와의상관관계에대해연구를시행하였으며 10-13), 한국성인에서신장기능과뇌졸중의예후에대해연구가거의이루어지지않은데의의가있다하겠다. 본연구에서저자들은만성신장질환의중증도를평가하기위해널리사용되는두가지공식인 Cockcroft-Gault 공식과 MDRD 공식을사용하여사구체여과율을측정하였다. 신장기능의평가를위해서혈장 creatinine 수치를참조할수있겠지만, creatinine 수치는개인의근육량에따라영향을받기때문에근육량이적은여성이나노인에서는사구체여과율이감소해있음에도 creatinine 수치가정상으로나타날수있기때문에주의를요한다. Cockcroft-Gault 공식은 creatinine, 성별, 나이, 몸무게를이용하여사구체여과율을측정하며 15), MDRD 연구에서제시된 abbreviated MDRD 공식은 creatinine, 성별, 나이만으로측정하여여러검사수치가필요한 orginal MDRD 공식에비해간단하며비슷한결과를나타낸다 19). 본연구에서 Cockcroft-Gault 공식의사구체여과율평균은 MDRD 공식의사구체여과율평균보다낮았으며사구체여과율 60 ml/min/1.73 m 2 미만인만성신부전의비율도높았다. 나이와몸무게의영향을많이받는 Cockcroft-Gault 공 식의특성상비교적고령인평균연령과낮은체질량지수가영향을미쳤을것으로생각된다 20). Cockcroft-Gault 공식으로사구체여과율을측정한군을보면만성신부전에서고령이며체질량지수는낮았으며높은 NHISS를보였다. 이는나이가많을수록사구체여과율이일정하게줄어드는것을반영한결과로사료되며 21), 체질량지수의감소는만성신장질환의진행과비례한영양결핍및염증의증가가영향을미쳤을것으로사료된다 22). 또한 NHISS로평가한급성뇌졸중의중증도에서는만성신장질환이진행할수록중증의뇌졸중이발생함을확인할수있었다. 만성신장질환이진행한군에서심근경색의과거력이유의하게높았으나그이외에는각군에서급성뇌졸중위험인자의차이는없었다. 본연구에서는사구체여과율을계산하는공식의종류에따라만성신장질환의유병률및사구체여과율의분포는차이를보였지만만성신장질환의중증도가급성뇌졸중환자에서사망률및요양기관재원율의증가를예측할수있는중요한인자임을확인할수있었다. Kaplan-Meier 생존곡선분포를보면두공식을사용한군에서모두만성신장질환의진행정도에따라급성허혈성뇌졸중환자의생존기간에통계적으로의의있는차이를보여주고있다 ( 그림 2). 또한만성신장질환의진행정도에따라 1개월, 1년후의사망률과요양기관재원율에대한 odds ratio 의의미있는증가를관찰할수있었으며이는나이, 성별, 흡연력, 빈혈, 고혈압, 당뇨등다른위험인자들을교정한후에도관찰되었다. 본연구의이러한결과는급성뇌졸중환자를대상으로하였던타연구에서확인되는결과와일치한다 10,12). 만성신장질환이허혈성뇌졸중의위험성을높이는기전에대해서는명확히밝혀져있지는않다. 다만신장기능이악화됨에따라빈혈, 산화스트레스, nitric oxide 합성억제, 염증및응고인자의활성화관찰되며이런요소들이죽상판경화증의악화, 내피세포의기능장애및혈전증의발생위험을증가시키는역할을한다고알려져있다 23-27). 만성신장질환이외에급성허혈성뇌졸중의예후에영향을미치는인자로는고령, 고혈압, 당뇨병, 흡연력, 고지혈증등이알려져있다 28). 그러나본연구에서는고령이외에상기위험인자들은사망률의증가와관계가없었다. 본연구의결과가타연구들과다른점은장기간추적관찰후에나타나는결과를비교했던타연구들과달리후향적으로분석하였으며상대적으로중증의만성신장질환환자그룹이적었기때문으로추정할수있겠다

7 - 대한내과학회지 : 제 78 권제 5 호통권제 597 호 본연구에는몇가지제한점들이존재한다. 첫째로, 자료수집은연속된기간동안급성뇌졸중으로내원한환자들을대상으로후향적으로수집하였다. 둘째로, 사구체여과율의측정은직접측정법이정확하나 serum creatinine과간단한임상자료들을이용하여계산하는간접측정법을이용하였다. 이는후향적으로자료가수집되었으며임상에서직접측정법을사용하기에는검사상의번거로움과비용문제등이있어서였다. 공식을사용하여측정된사구체여과율과실제사구체여과율사이에는차이가있을수있으며이로인해만성신장질환의중증도와급성뇌졸중의예후와의상관관계정도를과소또는과대평가했을수있다. 셋째로, 빈혈, 고혈압, 당뇨등과같이급성뇌졸중의사망률과병원재원율에영향을미칠수있는인자들에대해보정하여 odds ratio를산출하였지만예후에영향을미칠수있는고려가능한모든인자들 ( 단백뇨, 알부민뇨등 ) 을대상으로보정이이루어지지는않았다. 결론으로, 저자들은사구체여과율의감소와급성뇌졸중의예후의상관관계에대해기술하였다. 급성뇌졸중환자에서만성신장질환의중증도에따라사망률과요양기관재원율이증가함을확인할수있었다. National Kidney Foundation practice guideline을포함한권위있는진료지침들에서만성신장질환을심혈관계질환의고위험군으로분류할것을추천하고있다 1,2). 본연구는이러한내용을지지하는결과를보여주며동시에급성허혈성뇌졸중에서도적용되어야함을알려준다. 요약목적 : 만성신장질환은관상동맥질환의독립적인위험인자로알려져있다. 하지만심혈관질환의다른형태인급성허혈성뇌졸중과만성신장질환과의연관관계에대해서는아직잘알려져있지않다. 이에저자들은급성허혈성뇌졸중환자에서만성신장질환의진행정도에따라예후에미치는영향을알아보고자하였다. 방법 : 급성허혈성뇌졸중으로내원한환자 282예를대상으로후향적연구를통해만성신장질환의진행정도에따른예후와의상관관계를연구하였다. 사구체여과율은 Cockcroft- Gault 공식과 Modification of Diet in Renal Disease (MDRD) 공식을이용하여측정하였다. 사구체여과율에따라세군으로분류하여분석을시행하였다 (I 군 : ml/min/1.73 m 2, II 군 : ml/min/1.73 m 2, III 군 : ml/min/1.73 m 2 ). 급 성허혈성뇌졸중발생 1개월과 12개월후에추적관찰을통하여사구체여과율감소에따른사망률및요양기관재원률의차이를비교분석하였다. 결과 : Cockcroft-Gault 공식을사용한군의 1년사망률은 I 군에서 6.0%, II 군에서 20.3%, III 군에서 21.1% 였으며상대적으로 MDRD 공식을사용한군의 1년사망률은 9.1%, 12.5%, 37.5% 로관찰되었다. Cockcrfot-Gault 공식을사용한군의 1년사망률에대한 odds ratio 는 II 군에서 3.97 (1.7~9.2, 95% CI), III 군에서 4.16 (1.2~14.5, 95% CI) 이며사구체여과율의감소에따라 odds ratio 가증가하였다. MDRD 공식을사용한군에서 1년사망률에대한 odds ratio 는 1.43 (0.5~4.4, 95% CI), 6.00 (1.3~26.8, 95% CI) 으로관찰되었다. Adjusted odds ratio 는양공식을사용한군모두에서사구체여과율의감소에따라 odds ratio 의증가가관찰되었다. 결론 : 급성허혈성뇌졸중환자에서사구체여과율의감소및만성신장질환의중등도는사망률증가및불량한예후와관계가있었다. 중심단어 : 만성신장질환 ; 급성허혈성뇌졸중 ; 사망률 REFERENCES 1) Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 139: , ) Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, McCullough PA, Kasiske BL, Kelepouris E, Klag MJ, Parfrey P, Pfeffer M, Raij L, Spinosa DJ, Wilson PW. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 108: , ) Weiner DE, Tighiouart H, Amin MG, Stark PC, MacLeod B, Griffith JL, Salem DN, Levey AS, Sarnak MJ. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies. J Am Soc Nephrol 15: , ) National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 39(2 Suppl 1):S1-S266, ) Kim S, Lim CS, Han DC, Kim GS, Chin HJ, Kim SJ, Cho WY, Kim YH, Kim YS. The prevalence of chronic kidney disease (CKD) and the associated factors to CKD in urban Korea: a population-based cross-sectional epidemiologic study. J Korean Med

8 - 최준석외 11 인. 급성허혈성뇌졸중에서신장기능의영향 - Sci 24(Suppl ):S11-S21, ) Al Suwaidi J, Reddan DN, Williams K, Pieper KS, Harrington RA, Califf RM, Granger CB, Ohman EM, Holmes DR Jr. Prognostic implications of abnormalities in renal function in patients with acute coronary syndromes. Circulation 106: , ) Anavekar NS, McMurray JJ, Velazquez EJ, Solomon SD, Kober L, Rouleau JL, White HD, Nordlander R, Maggioni A, Dickstein K, Zelenkofske S, Leimberger JD, Califf RM, Pfeffer MA. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med 351: , ) McCullough PA, Soman SS, Shah SS, Smith ST, Marks KR, Yee J, Borzak S. Risks associated with renal dysfunction in patients in the coronary care unit. J Am Coll Cardiol 36: , ) Sadeghi HM, Stone GW, Grines CL, Mehran R, Dixon SR, Lansky AJ, Fahy M, Cox DA, Garcia E, Tcheng JE, Griffin JJ, Stuckey TD, Turco M, Carroll JD. Impact of renal insufficiency in patients undergoing primary angioplasty for acute myocardial infarction. Circulation 108: , ) Koren-Morag N, Goldbourt U, Tanne D. Renal dysfunction and risk of ischemic stroke or TIA in patients with cardiovascular disease. Neurology 67: , ) MacWalter RS, Wong SY, Wong KY, Stewart G, Fraser CG, Fraser HW, Ersoy Y, Ogston SA, Chen R. Does renal dysfunction predict mortality after acute stroke?: a 7-year follow-up study. Stroke 33: , ) Yahalom G, Schwartz R, Schwammenthal Y, Merzeliak O, Toashi M, Orion D, Sela BA, Tanne D. Chronic kidney disease and clinical outcome in patients with acute stroke. Stroke 40: , ) Friedman PJ. Serum creatinine: an independent predictor of survival after stroke. J Intern Med 229: , ) Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20: , ) Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 16:31-41, ) Brosius FC 3rd, Hostetter TH, Kelepouris E, Mitsnefes MM, Moe SM, Moore MA, Pennathur S, Smith GL, Wilson PW. Detection of chronic kidney disease in patients with or at increased risk of cardiovascular disease: a science advisory from the American Heart Association Kidney And Cardiovascular Disease Council; the Councils on High Blood Pressure Research, Cardiovascular Disease in the Young, and Epidemiology and Prevention; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: developed in collaboration with the National Kidney Foundation. Circulation 114: , ) Seliger SL, Gillen DL, Longstreth WT Jr, Kestenbaum B, Stehman- Breen CO. Elevated risk of stroke among patients with end-stage renal disease. Kidney Int 64: , ) Toyoda K, Fujii K, Fujimi S, Kumai Y, Tsuchimochi H, Ibayashi S, Iida M. Stroke in patients on maintenance hemodialysis: a 22-year single-center study. Am J Kidney Dis 45: , ) Lin J, Knight EL, Hogan ML, Singh AK. A comparison of prediction equations for estimating glomerular filtration rate in adults without kidney disease. J Am Soc Nephrol 14: , ) Cirillo M, Anastasio P, De Santo NG. Relationship of gender, age, and body mass index to errors in predicted kidney function. Nephrol Dial Transplant 20: , ) Lindeman RD, Tobin J, Shock NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 33: , ) Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, Kusek JW, Van Lente F. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 145: , ) D'Elia JA, Weinrauch LA, Gleason RE, Lipinska I, Lipinski B, Lee AT, Tofler GH. Risk factors for thromboembolic events in renal failure. Int J Cardiol 101:19-25, ) Johnson DW, Armstrong K, Campbell SB, Mudge DW, Hawley CM, Coombes JS, Prins JB, Isbel NM. Metabolic syndrome in severe chronic kidney disease: prevalence, predictors, prognostic significance and effects of risk factor modification. Nephrology (Carlton) 12: , ) McCullough PA, Jurkovitz CT, Pergola PE, McGill JB, Brown WW, Collins AJ, Chen SC, Li S, Singh A, Norris KC, Klag MJ, Bakris GL. Independent components of chronic kidney disease as a cardiovascular risk state: results from the Kidney Early Evaluation Program (KEEP). Arch Intern Med 167: , ) Soriano S, Gonzalez L, Martin-Malo A, Rodriguez M, Aljama P. C-reactive protein and low albumin are predictors of morbidity and cardiovascular events in chronic kidney disease (CKD) 3-5 patients. Clin Nephrol 67: , ) Valkonen VP, Paiva H, Salonen JT, Lakka TA, Lehtimaki T, Laakso J, Laaksonen R. Risk of acute coronary events and serum concentration of asymmetrical dimethylarginine. Lancet 358: , ) Goldstein LB, Adams R, Becker K, Furberg CD, Gorelick PB, Hademenos G, Hill M, Howard G, Howard VJ, Jacobs B, Levine SR, Mosca L, Sacco RL, Sherman DG, Wolf PA, del Zoppo GJ. Primary prevention of ischemic stroke: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation 103: ,

저작자표시 - 비영리 - 변경금지 2.0 대한민국 이용자는아래의조건을따르는경우에한하여자유롭게 이저작물을복제, 배포, 전송, 전시, 공연및방송할수있습니다. 다음과같은조건을따라야합니다 : 저작자표시. 귀하는원저작자를표시하여야합니다. 비영리. 귀하는이저작물을영리목적으로이용할

저작자표시 - 비영리 - 변경금지 2.0 대한민국 이용자는아래의조건을따르는경우에한하여자유롭게 이저작물을복제, 배포, 전송, 전시, 공연및방송할수있습니다. 다음과같은조건을따라야합니다 : 저작자표시. 귀하는원저작자를표시하여야합니다. 비영리. 귀하는이저작물을영리목적으로이용할수없습니다. 변경금지. 귀하는이저작물을개작, 변형또는가공할수없습니다. 귀하는, 이저작물의재이용이나배포의경우,