中国3种主要病因特异性慢性肾脏病归因于代谢与生活方式相关危险因素的疾病负担及变化趋势

麦哲芬,  莫雨晓,  莫梅兰,  林德荣,  梁靖蓉,  张维晴,  韩霞

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引用本文: 麦哲芬，莫雨晓，莫梅兰，等．中国3种主要病因特异性慢性肾脏病归因于代谢与生活方式相关危险因素的疾病负担及变化趋势［J］．海军军医大学学报，2026，47（8）：1070-1082．DOI: 10.16781/j.CN31-2187/R.20260248.
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Citation: Mai Z, Mo Y, Mo M, et al. Burden and temporal trends of 3 major etiology-specific chronic kidney diseases attributable to metabolic and lifestyle-related risk factors in China［J］. Acad J Naval Med Univ, 2026, 47(8): 1070-1082. DOI: 10.16781/j.CN31-2187/R.20260248.
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中国3种主要病因特异性慢性肾脏病归因于代谢与生活方式相关危险因素的疾病负担及变化趋势

doi: 10.16781/j.CN31-2187/R.20260248
  • 1.

    广州中医药大学深圳医院(福田)妇科, 深圳 518034;

  • 2.

    广州中医药大学附属广州中医医院急诊科, 广州 510006;

  • 3.

    广州中医药大学东莞医院妇产科, 东莞 523000;

  • 4.

    深圳市龙华区人民医院中医科, 深圳 518000

基金项目: 

国家自然科学基金青年科学基金 82305387;

深圳市中医药学会项目 2024020;

广东省中医药管理局面上项目 20251324;

福田区卫生健康局项目 FTWS2025045;

深圳市龙华区医疗卫生机构区级科研项目 2022013.

详细信息
    作者简介:

    麦哲芬，博士，医师. E-mail: maizhefen@126.com.

    通讯作者:

    韩霞, E-mail: hanxia@gzucm.edu.cn.

Burden and temporal trends of 3 major etiology-specific chronic kidney diseases attributable to metabolic and lifestyle-related risk factors in China

  • 1.

    Department of Gynecology, Shenzhen Hospital (Futian) of Guangzhou University of Chinese Medicine, Shenzhen 518034, Guangdong, China;

  • 2.

    Department of Emergency, The Affiliated Guangzhou Hospital of TCM of Guangzhou University of Chinese Medicine, Guangzhou 510006, Guangdong, China;

  • 3.

    Department of Obstetrics and Gynecology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan 523000, Guangdong, China;

  • 4.

    Department of Traditional Chinese Medicine, Longhua District People's Hospital of Shenzhen, Shenzhen 518000, Guangdong, China

Funds: 

Young Scientist Fund of National Natural Science Foundation of China 82305387;

Program of Shenzhen Association of Traditional Chinese Medicine 2024020;

General Program of Guangdong Provincial Administration of Traditional Chinese Medicine 20251324;

Health Bureau Program of Futian District FTWS2025045;

District-level Scientific Research Project of Medical and Health Institution of Shenzhen Longhua District 2022013.

    摘要
  • 摘要:
    目的 

    基于全球疾病负担研究2023（GBD 2023）数据，分析1990－2023年中国3种主要病因特异性慢性肾脏病（CKD）归因于代谢与生活方式相关危险因素的疾病负担变化、风险结构、人群分布及未来趋势。

    方法 

    基于GBD 2023数据库，提取中国2型糖尿病所致慢性肾脏病（T2DM-CKD）、高血压所致慢性肾脏病（HTN-CKD）和肾小球肾炎所致慢性肾脏病（GN-CKD）归因于8项代谢与生活方式相关危险因素的伤残调整生命年（DALY）及年龄标化DALY率（ASDR）数据。分析1990年与2023年中国及传统金砖国家（巴西、俄罗斯、印度、中国和南非）的疾病负担变化，并进行性别、年龄分层分析和2024－2035年自回归积分滑动平均模型（ARIMA）预测。采用1990－2023年逐年ASDR的对数线性回归模型计算估计年度变化百分比（EAPC）及其95%CI；同时计算8项危险因素内部构成比以描述风险结构演变。

    结果 

    1990－2023年，中国3种CKD归因8项危险因素DALY总体增加，但ASDR变化分化。在GN-CKD中，高空腹血糖始终为首位归因危险因素，其ASDR的EAPC为－3.98%（95%CI －4.44%~－3.53%），内部构成比由1990年的65.9%降至2023年的39.5%；高收缩压构成比由12.1%升至27.3%。HTN-CKD始终以高收缩压为首位归因危险因素，其ASDR的EAPC为－0.60%（95%CI －0.85%~－0.34%），但高BMI归因ASDR的EAPC为0.69%（95%CI 0.42%~0.96%）。T2DM-CKD绝对负担增幅最大，高空腹血糖和高BMI长期居前2位，其中高空腹血糖归因ASDR的EAPC为－1.33%（95%CI －1.45%~－1.20%）。3种病因特异性CKD各危险因素归因负担明显向50岁及以上人群聚集。传统金砖国家间GN-CKD风险构成异质性最强，HTN-CKD一致性最高。ARIMA预测显示，2024－2035年GN-CKD归因负担总体下降，而HTN-CKD和T2DM-CKD仍将持续上升。

    结论 

    1990－2023年，中国3种主要病因特异性CKD归因于代谢与生活方式相关危险因素的绝对负担持续扩张，但风险结构和变化趋势存在明显分化。绝对负担上升而ASDR下降提示人口老龄化和人口规模增长是CKD负担扩张的重要背景。分病因、分年龄实施血糖-体重、血压-限盐及专科随访协同管理，可能是未来降低CKD负担的关键。

     

    Abstract:
    Objective 

    To analyze the disease burden, risk structure, population distribution, and future trends of 3 major etiology-specific chronic kidney diseases (CKDs) attributable to metabolic and lifestyle-related risk factors in China from 1990 to 2023 based on data from the Global Burden of Disease Study 2023 (GBD 2023).

    Methods 

    The disability-adjusted life year (DALY) and age-standardized DALY rate (ASDR) data of chronic kidney disease due to type 2 diabetes mellitus (T2DM-CKD), chronic kidney disease due to hypertension (HTN-CKD), and chronic kidney disease due to glomerulonephritis (GN-CKD) attributable to 8 metabolic and lifestyle-related risk factors in China were obtained from the GBD 2023 database. The burden changes in China and traditional BRICS countries (Brazil, Russia, India, China, and South Africa) in 1990 and 2023 were analyzed. Gender- and age-stratified analyses were performed, and the future trends from 2024 to 2035 were projected using an autoregressive integrated moving average (ARIMA) model. The estimated annual percentage change (EAPC) and its 95% confidence interval (95%CI) were calculated using a log-linear regression model fitted to annual ASDRs from 1990 to 2023. Meanwhile, the internal composition ratios of the 8 risk factors were calculated to characterize the evolution of the risk structure.

    Results 

    From 1990 to 2023, the overall DALYs of the 3 types of CKDs attributable to 8 risk factors in China were increased, whereas the changes in ASDRs diverged. For GN-CKD, high fasting plasma glucose remained the leading attributable risk factor, with an EAPC of the ASDR of -3.98% (95%CI -4.44% to -3.53%), and its internal composition ratio decreased from 65.9% in 1990 to 39.5% in 2023; the composition ratio attributable to high systolic blood pressure increased from 12.1% to 27.3%. For HTN-CKD, high systolic blood pressure remained the predominant attributable risk factor, with an EAPC of the ASDR of -0.60% (95%CI -0.85% to -0.34%); the EAPC of the ASDR attributable to high body mass index (BMI) was 0.69% (95%CI 0.42% to 0.96%). T2DM-CKD showed the greatest increase in absolute burden, with high fasting plasma glucose and high BMI consistently ranking as the top 2 risk factors; the EAPC of the ASDR attributable to high fasting plasma glucose was -1.33% (95%CI -1.45% to -1.20%). The attributable burden of all risk factors for the 3 etiology-specific CKDs was predominantly concentrated among individuals aged 50 years and older. Among traditional BRICS countries, GN-CKD showed the highest heterogeneity in risk structure, while HTN-CKD showed the highest consistency. ARIMA projections suggested that the attributable burden of GN-CKD would generally decline from 2024 to 2035, while the burdens of HTN-CKD and T2DM-CKD would continue to rise.

    Conclusion 

    From 1990 to 2023, the absolute burden attributable to metabolic and lifestyle-related risk factors for the 3 major etiology-specific CKDs in China has continued to expand, but the risk structures and temporal trends differ substantially. The rise in absolute burden and decline in ASDR suggest that population aging and population growth are important contextual factors driving CKD burden expansion. Etiology- and age-specific integrated management strategies targeting glycemia and body weight control, blood pressure control and salt reduction, and specialist follow-up may be the keys for reducing the future burden of CKDs.

     

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  • 慢性肾脏病（chronic kidney disease，CKD）是全球重要的慢性非传染性疾病之一，具有患病率高、致残负担重和死亡风险高等特点，已成为严重威胁人类健康的公共卫生问题[1-3]。全球疾病负担研究（Global Burden of Disease Study，GBD）2023数据显示，中国作为CKD高发国家之一，CKD患病人数、死亡人数和疾病负担不容忽视[4-5]。全国性监测研究进一步提示，2018－2019年我国成年居民CKD患病人数约为8 200万，提示CKD仍是我国慢性病防控体系中不可忽视的重要疾病[6]。CKD并非单一疾病实体，按病因学进行分层分析更有助于揭示其流行病学异质性并明确防控重点。改善全球肾脏病预后组织（Kidney Disease: Improving Global Outcomes，KDIGO）2024年发布的《慢性肾脏病评估与管理临床实践指南》强调，应结合病因、肾小球滤过率和蛋白尿水平开展CKD风险分层与管理[7]。中国CKD疾病负担研究显示，2型糖尿病所致慢性肾脏病（chronic kidney disease due to type 2 diabetes mellitus，T2DM-CKD）和高血压所致慢性肾脏病（chronic kidney disease due to hypertension，HTN-CKD）负担持续上升，而肾小球肾炎所致慢性肾脏病（chronic kidney disease due to glomerulonephritis，GN-CKD）虽然部分年龄标化指标有所下降，但仍是我国CKD负担的重要组成部分[8]。

    CKD的发生和进展除受原发病因影响外，还与多种可干预危险因素的长期暴露密切相关。GBD比较风险评估框架表明，高空腹血糖、高收缩压和高BMI是CKD负担增加的核心代谢驱动因素，而膳食失衡和体力活动不足则构成其重要的生活方式危险因素[9-10]。不同病因特异性CKD的主导危险因素并不完全一致。针对中国T2DM-CKD的研究表明，其疾病负担在过去30余年持续增长，且老龄化是最主要的驱动因素[11]。全球HTN-CKD研究显示，该病因相关负担持续上升，并存在明显的年龄和性别差异[12]。GN-CKD研究则提示，高空腹血糖、高BMI和高收缩压是其主要可归因危险因素，且未来负担可能呈缓慢降低趋势[13]。

    现有研究多聚焦于总体CKD负担或单一病因的变化[8,11-13]，而在同一研究框架下同时纳入T2DM-CKD、HTN-CKD和GN-CKD，系统比较其危险因素构成、国际差异、人群分布及未来趋势的研究仍较少。本研究基于GBD 2023数据库，系统分析了1990－2023年中国T2DM-CKD、HTN-CKD和GN-CKD归因于代谢与生活方式相关危险因素的疾病负担变化，并进一步开展传统金砖国家（巴西、俄罗斯、印度、中国和南非）的对比分析、性别与年龄分层分析及趋势预测，以期为我国CKD分层防控和精准干预提供循证依据。

    1   资料和方法

    1.1   资料来源

    本研究为基于公开数据库的描述性流行病学研究。数据来源于GBD 2023数据库，并通过全球健康数据交换平台（Global Health Data Exchange）和GBD Results Tool提取相关数据[4]。GBD采用统一的疾病分类标准、标准化估计方法和比较风险评估框架，可在国家层面提供具有可比性的疾病及危险因素负担估计结果[4,14]。本研究所用数据均为公开汇总数据，不涉及个人隐私信息，故无需伦理审批。

    1.2   研究病种与定义

    本研究纳入3种主要病因特异性CKD，即T2DM-CKD、HTN-CKD和GN-CKD。选择上述3种病因的依据在于：病因分类明确，具有较好的同质性和可解释性，能够分别代表代谢性驱动、血压相关驱动和传统肾脏专科病因驱动的CKD负担模式。CKD的界定参照KDIGO 2024版《慢性肾脏病评估与管理临床实践指南》[7]，分型则与GBD 2023的病因分层[5]保持一致。

    1.3   危险因素界定

    依据GBD比较风险评估框架，本研究重点聚焦代谢与生活方式相关危险因素，纳入8项核心暴露因素，包括高空腹血糖、高收缩压、高BMI、低体力活动、低水果饮食、低蔬菜饮食、高钠饮食和低全谷物饮食。考虑到肾功能障碍更接近近端临床或病理风险，而铅暴露、高温暴露和低温暴露属于环境暴露因素[9]，为保持研究主题聚焦及方法学一致性，上述因素未纳入本研究分析。

    1.4   研究指标与数据提取

    本研究以伤残调整生命年（disability-adjusted life year，DALY）作为主要疾病负担指标，以年龄标化伤残调整生命年率（age-standardized DALY rate，ASDR）作为主要比较率指标，所有结果均报告95%不确定区间（95% uncertainty interval，95%UI）[14]。利用GBDResults Tool提取measure_name、location_name、sex_name、age_name、cause_name、rei_name、metric_name、year、val、lower和upper等字段。研究地区为中国；国际比较对象为传统金砖国家。性别分层包括男性和女性；年龄分层采用GBD Results Tool预设并可稳定反映生命周期差异的3个年龄组：15~49岁、50~69岁和≥70岁。分析时间范围为1990－2023年，预测期为2024－2035年。

    1.5   统计学处理

    采用Microsoft Excel 16.109.3和R 4.4.2软件进行数据整理、统计分析及绘图。首先，对1990－2023年中国3种主要病因特异性CKD归因于8项代谢与生活方式相关危险因素的DALY和ASDR进行描述性分析，比较不同病因、不同危险因素及不同时期的CKD负担水平与排序变化。其次，比较1990年与2023年传统金砖国家相关归因DALY及其内部构成比，以评估中国与其他国家在病因谱和风险谱方面的异同。再次，开展性别和年龄分层分析，以识别不同人群中的高负担病因和主导危险因素；趋势预测采用自回归积分滑动平均模型（autoregressive integrated moving average，ARIMA）对1990－2023年DALY序列进行建模并外推至2035年。此外，参照既往GBD趋势研究及趋势分析方法学文献[12-13,15]，以1990－2023年逐年ASDR为因变量、年份为自变量建立对数线性回归模型：ln(ASDR)＝α+b×年份+ε，其中α为截距项，b为回归系数（表示ASDR对数值随年份变化的平均线性变化幅度），ε为随机误差项。采用1990－2023年逐年ASDR的对数线性回归模型计算估计年度变化百分比（estimated annual percentage change，EAPC）及其95%CI，计算公式为EAPC＝100%×(expb－1)。若EAPC及其95%CI下限均大于0，表示ASDR呈上升趋势；若EAPC及其95%CI上限均小于0，表示ASDR呈下降趋势。考虑到GBD比较风险评估框架对各危险因素采用独立归因估计，危险因素间的交互作用和共线性未纳入显式建模，不同危险因素的归因负担可能存在重叠，因此本研究不对8项危险因素的归因DALY或ASDR进行简单加总，也未将其直接解释为病因总负担的可相加组成；为描述风险结构演变特征，仅计算8项危险因素的内部构成比。

    2   结果

    2.1   1990－2023年中国3种主要病因特异性CKD归因负担总体上升且风险谱分化明显

    1990－2023年，中国人群归因于8项代谢与生活方式相关危险因素的3种主要病因特异性CKD绝对负担总体上升，但ASDR变化并不同步，提示在人口老龄化和人口规模增长背景下，绝对负担扩张与年龄标化风险变化并存。GN-CKD中，高空腹血糖始终为首位归因危险因素，但其相关DALY由1990年的94 410人年（95%UI 11 290~218 708人年）降至2023年的77 872人年（95%UI 9 176~186 703人年），ASDR由9.01/10万降至3.75/10万，EAPC为－3.98%（95%CI －4.44%~－3.53%）；同期高收缩压相关DALY由17 279人年增至53 925人年，ASDR由2.01/10万升至2.36/10万，但基于1990－2023年逐年序列拟合的EAPC为－0.85%（95%CI －1.26%~－0.45%）。HTN-CKD始终以高收缩压为首位归因危险因素，其相关DALY由1990年的317 746人年增至2023年的676 130人年，ASDR由43.73/10万降至30.23/10万，EAPC为－0.60%（95%CI －0.85%~－0.34%）；高BMI相关ASDR由8.36/10万升至9.13/10万，EAPC为0.69%（95%CI 0.42%~0.96%）。T2DM-CKD绝对负担增幅最大，高空腹血糖和高BMI长期位居前2位，其中高空腹血糖相关DALY由1990年的604 036人年增至2023年的1 041 016人年，ASDR由72.09/10万降至44.30/10万，EAPC为－1.33%（95%CI －1.45%~－1.20%）；高BMI相关DALY由169 921人年增至407 874人年，ASDR由18.70/10万降至17.20/10万，EAPC为－0.24%（95%CI －0.41%~－0.07%）。见表 1。

    表  1  1990年与2023年中国3种主要病因特异性慢性肾脏病归因于8项代谢与生活方式相关危险因素的DALY、ASDR及EAPC
    Table  1  DALY, ASDR, and EAPC of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in China in 1990 and 2023
    Risk factor 1990 2023 EAPC (95%CI)/%
    DALY (95%UI)/ (person-year) ASDR (95%UI)/(×10－5) DALY (95%UI)/ (person-year) ASDR (95%UI)/(×10－5)
    GN-CKD
      High fasting plasma glucose 94 410 (11 290, 218 708) 9.01 (1.01, 21.68) 77 872 (9 176, 186 703) 3.75 (0.47, 8.80) －3.98 (－4.44, －3.53)
      High systolic blood pressure 17 279 (0, 94 999) 2.01 (0.00, 10.86) 53 925 (6, 195 360) 2.36 (0.00, 8.89) －0.85 (－1.26, －0.45)
      High body mass index 12 468 (141, 55 109) 1.17 (0.01, 5.17) 27 138 (673, 73 829) 1.24 (0.03, 3.56) －1.24 (－1.65, －0.84)
      Low physical activity 327 (2, 1 509) 0.04 (0.00, 0.21) 961 (33, 4 381) 0.05 (0.00, 0.20) －0.73 (－1.15, －0.30)
      Diet low in fruits 7 508 (51, 33 342) 0.81 (0.01, 3.66) 14 874 (194, 48 623) 0.67 (0.01, 2.26) －1.87 (－2.25, －1.49)
      Diet low in vegetables 2 296 (2, 12 350) 0.27 (0.00, 1.43) 1 166 (4, 5 268) 0.05 (0.00, 0.24) －5.91 (－6.55, －5.27)
      Diet high in sodium 7 083 (0, 47 002) 0.79 (0.00, 5.32) 19 967 (1, 98 786) 0.87 (0.00, 4.44) －1.00 (－1.39, －0.62)
      Diet low in whole grains 1 840 (2, 11 349) 0.17 (0.00, 1.02) 1 421 (9, 7 324) 0.07 (0.00, 0.36) －4.18 (－4.77, －3.58)
    HTN-CKD
      High fasting plasma glucose 48 587 (4 054, 130 294) 7.23 (0.89, 17.84) 127 575 (24 793, 279 861) 5.93 (1.25, 12.75) －0.09 (－0.31, 0.12)
      High systolic blood pressure 317 746 (143 504, 489 909) 43.73 (20.38, 67.53) 676 130 (386 310, 887 021) 30.23 (17.22, 39.77) －0.60 (－0.85, －0.34)
      High body mass index 73 620 (26 773, 142 105) 8.36 (3.06, 16.17) 205 238 (92 560, 355 460) 9.13 (4.07, 15.80) 0.69 (0.42, 0.96)
      Low physical activity 491 (5, 2 331) 0.12 (0.00, 0.46) 2 454 (100, 9 246) 0.12 (0.01, 0.46) 0.55 (0.26, 0.84)
      Diet low in fruits 122 593 (61 061, 199 952) 15.91 (8.00, 26.12) 179 310 (96 474, 260 672) 8.11 (4.27, 11.72) －1.52 (－1.78, －1.25)
      Diet low in vegetables 44 506 (11 852, 85 497) 6.30 (1.82, 11.73) 18 107 (3 534, 45 493) 0.84 (0.16, 2.16) －5.20 (－5.93, －4.47)
      Diet high in sodium 140 798 (30 925, 290 101) 17.42 (3.45, 36.88) 219 747 (55 272, 441 655) 9.55 (2.30, 19.45) －1.27 (－1.51, －1.03)
      Diet low in whole grains 981 (2, 5 842) 0.15 (0.00, 0.84) 2 994 (44, 11 441) 0.14 (0.00, 0.52) 0.38 (0.07, 0.68)
    T2DM-CKD
      High fasting plasma glucose 604 036 (415 698, 828 929) 72.09 (50.42, 98.80) 1 041 016 (799 849, 1 296 046) 44.30 (34.31, 55.25) －1.33 (－1.45, －1.20)
      High systolic blood pressure 34 821 (0, 181 435) 4.31 (0.00, 22.64) 121 282 (4, 407 929) 5.07 (0.00, 17.20) 0.47 (0.29, 0.64)
      High body mass index 169 921 (65 952, 317 321) 18.70 (7.09, 34.95) 407 874 (175 697, 706 244) 17.20 (7.40, 29.77) －0.24 (－0.41, －0.07)
      Low physical activity 40 523 (13 372, 73 963) 5.08 (1.67, 9.28) 78 272 (30 149, 132 659) 3.35 (1.30, 5.72) －1.27 (－1.42, －1.12)
      Diet low in fruits 44 818 (8 750, 96 847) 5.26 (1.08, 11.65) 70 073 (16 762, 143 627) 2.96 (0.71, 6.02) －1.64 (－1.79, －1.50)
      Diet low in vegetables 8 374 (253, 27 506) 1.03 (0.04, 3.38) 3 823 (179, 15 910) 0.16 (0.01, 0.68) －5.21 (－5.88, －4.53)
      Diet high in sodium 13 505 (0, 82 534) 1.58 (0.00, 9.98) 42 558 (1, 209 138) 1.76 (0.00, 8.65) 0.34 (0.14, 0.54)
      Diet low in whole grains 38 372 (10 639, 72 603) 4.46 (1.21, 8.54) 53 859 (15 571, 101 849) 2.29 (0.66, 4.30) －1.89 (－2.02, －1.77)
    DALY: Disability-adjusted life year; ASDR: Age-standardized DALY rate; EAPC: Estimated annual percentage change; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus; 95%UI: 95% uncertainty interval; 95%CI: 95% confidence interval.

    从8项危险因素内部构成看，GN-CKD风险谱变化最为明显，高空腹血糖构成比由65.9%降至39.5%，而高收缩压由12.1%升至27.3%，高BMI由8.7%升至13.8%，提示其归因结构由单一因素主导转向多因素并存。HTN-CKD风险谱整体最稳定，高收缩压构成比由42.4%升至47.2%，始终居首；高BMI由9.8%升至14.3%，提示肥胖相关负担上升。T2DM-CKD中，高空腹血糖虽仍占主导，但构成比由63.3%降至57.2%，高BMI由17.8%升至22.4%，高收缩压由3.6%升至6.7%，表明糖脂代谢与血压异常的协同影响逐渐增强。

    2.2   1990－2023年传统金砖国家3种主要病因特异性CKD归因负担整体呈增加趋势且风险构成差异显著

    1990－2023年，传统金砖国家归因于8项代谢与生活方式相关危险因素的3种主要病因特异性CKD的DALY总体均呈增加趋势，但各国负担水平及增幅差异明显。在GN-CKD方面，1990年中国负担最高，2023年则印度居于首位；在HTN-CKD方面，2023年印度负担最高，中国次之；在T2DM-CKD方面，中国在1990年和2023年均为负担最高国家。总体来看，中国与印度是传统金砖国家中3种CKD归因主要高负担国家。见图 1。

    图  1  1990年与2023年传统金砖国家归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY比较
    Fig.  1  Comparison of DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in traditional BRICS countries in 1990 and 2023
    The numbers in the cells indicate the within-panel ranking of risk factors for each country according to attributable DALY, from rank 1, the highest burden, to rank 8, the lowest burden. DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.
    下载: 全尺寸图片

    从风险谱来看，GN-CKD国家间异质性最为突出：1990年中国和巴西均以高空腹血糖为首位归因危险因素，印度和俄罗斯以高收缩压居首位，南非则以高BMI居首位；至2023年，中国仍以高空腹血糖为主，俄罗斯仍以高收缩压居首位，南非仍以高BMI居首位，而巴西和印度则分别转为高BMI、高空腹血糖占首位。相对而言，HTN-CKD的国家间一致性最高，1990年和2023年传统金砖国家均以高收缩压为首位归因危险因素；T2DM-CKD则以高空腹血糖长期占主导，但巴西、俄罗斯和印度高BMI的重要性上升明显。见图 2。

    图  2  1990年与2023年传统金砖国家归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY构成比比较
    Fig.  2  Comparison of proportion of DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in traditional BRICS countries in 1990 and 2023
    DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.
    下载: 全尺寸图片

    2.3   中国3种主要病因特异性CKD性别差异相对稳定而年龄负担明显向中老年聚集

    性别分层分析结果显示，1990－2023年中国3种主要病因特异性CKD归因负担在男女两性间总体变化方向一致，但病种间性别差异程度不同。1990－2023年GN-CKD两性风险谱整体相近，2023年男女均以高空腹血糖和高收缩压为前2位归因危险因素；1990－2023年HTN-CKD和T2DM-CKD则均表现为男性总体归因DALY高于女性，尤其在高空腹血糖、高BMI和高钠饮食相关负担上差异明显，提示男性是代谢与生活方式相关CKD归因负担的重点防控对象。见图 3。

    图  3  1990－2023年中国不同性别人群归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY
    Fig.  3  DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors by gender stratification in China from 1990 to 2023
    DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.
    下载: 全尺寸图片

    年龄分层分析结果显示，2023年中国3种主要病因特异性CKD归因负担整体向中老年人群聚集。GN-CKD以50~69岁组负担最高；HTN-CKD年龄聚集现象最为突出，负担高峰位于≥70岁组；T2DM-CKD则主要集中于50~69岁组和≥70岁组。不同年龄层的首位危险因素亦存在差异，但总体均指向中老年人群中血糖、血压和体重管理的重要性。见图 4。

    图  4  2023年中国不同年龄段人群归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY
    Fig.  4  DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in different age groups in China in 2023
    DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.
    下载: 全尺寸图片

    2.4   2024－2035年中国3种主要病因特异性CKD归因负担预测呈分化趋势

    ARIMA模型预测显示，2024－2035年中国归因于8项代谢与生活方式相关危险因素的3种主要病因特异性CKD的DALY将呈现明显分化趋势。与2023年相比，2035年GN-CKD相关DALY预计由197 322.81人年降至162 499.62人年，降幅约17.6%；HTN-CKD相关DALY由1 431 554.47人年升至1 591 189.31人年，增幅约11.2%；T2DM-CKD相关DALY由1 818 757.81人年升至2 198 925.07人年，增幅约20.9%。提示未来我国CKD负担可能仍主要集中于与血压和代谢异常相关的病因类型，其中T2DM-CKD负担的增长幅度最大。见图 5。

    图  5  2024－2035年中国归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY预测趋势
    Fig.  5  Projected DALY trends of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in China from 2024 to 2035
    The red solid line represents observed DALY from 1990 to 2023, the yellow solid line represents projected DALY from 2024 to 2035, the semi-transparent yellow band represents the 95% confidence interval, and the gray dashed line marks the start of the projection period. DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.
    下载: 全尺寸图片

    从动态变化趋势分析，GN-CKD在2024年后总体呈缓慢下降趋势，虽2030年后略有回升，但至2035年仍低于2023年水平；HTN-CKD在短暂回落后重新转为上升，并在2030年后持续增长；T2DM-CKD预测曲线最为陡峭，2024年略下降后即持续上升，且预测区间整体上移。总体而言，未来GN-CKD负担可能趋于下降，而HTN-CKD和T2DM-CKD负担仍将持续增加，这提示临床与公共卫生领域应更加重视与血糖、血压及体重管理相关的综合干预措施，以遏制相关CKD负担的持续增长。见图 5。

    3   讨论

    本研究基于GBD 2023统一框架，对中国3种主要病因特异性CKD归因于8项代谢与生活方式相关危险因素的长期变化、国际差异、人群分布及2024－2035年趋势进行了系统分析，主要发现有3点：（1）1990－2023年3种CKD的绝对归因负担均总体上升，而多数归因危险因素的ASDR下降或相对稳定，提示人口老龄化和人口规模增长是绝对负担扩张的重要背景；（2）不同病因的风险结构演变不一致，HTN-CKD稳定以高收缩压为核心，T2DM-CKD长期受高空腹血糖和高BMI主导，GN-CKD则呈现更强的国家间异质性和由单一因素主导向多因素并存的结构变化；（3）3种CKD疾病负担明显向50岁及以上人群聚集，且未来HTN-CKD和T2DM-CKD负担仍将持续上升。

    HTN-CKD在时间、国家和年龄层面均表现出较强一致性：无论在中国还是传统金砖国家，高收缩压始终是首位归因危险因素，且其负担主要集中于老年人群。这一结果与高血压长期暴露导致肾小球高灌注、高滤过及肾小动脉硬化的病理过程相符，也与近年来GBD专题研究的结论[10,12]一致。值得注意的是，虽然高收缩压相关ASDR下降，但其绝对DALY仍持续上升，提示单纯依靠年龄标化风险下降尚不足以抵消老龄化带来的负担扩张。与此同时，高BMI在HTN-CKD内部风险谱中的构成比持续升高，说明除血压控制外，体重管理也已成为不可忽视的协同干预环节。

    T2DM-CKD的风险结构最为清晰：高空腹血糖和高BMI长期位居前2位，且绝对负担增幅最大。GBD 2021研究同样表明，T2DM-CKD是中国CKD负担增长最快的主要病因之一[11,16]。近年临床管理策略已由单纯降糖转向兼顾减重、降压和肾脏保护的综合干预。FLOW研究及相关meta分析提示，胰高糖素样肽-1受体激动剂可改善糖尿病合并CKD患者的肾脏和心血管结局[17-18]；钠-葡萄糖协同转运蛋白2抑制剂（如恩格列净、达格列净及卡格列净）的肾脏获益也已在随机对照试验[19-21]中得到证实。因此，对T2DM-CKD而言，更合理的干预路径不是单一针对高血糖，而是在“糖尿病前期-超重肥胖-早期肾损害”连续谱上前移实施“血糖-体重-肾脏”协同管理。

    GN-CKD风险结构的解释需更为审慎。肾小球肾炎并非典型代谢驱动性疾病，本研究中高空腹血糖、高收缩压或高BMI居前，更多反映GBD比较风险评估框架下这些危险因素与GN-CKD负担之间的统计归因关联，而不宜直接等同于肾小球肾炎发生、发展的单一病因机制[13]。同时，GN-CKD在传统金砖国家间的首位危险因素差异明显，提示不同国家在原发肾小球疾病谱、代谢异常流行水平、基层慢性病管理和专科诊疗可及性方面可能存在差异[22-23]。中国与印度GN-CKD负担较高，可能与人口基数大、糖代谢异常流行及CKD早筛覆盖不足等因素有关；俄罗斯高收缩压相关负担突出，则可能与高血压控制不足及心肾共病负担有关；巴西和南非高BMI相关贡献上升，提示肥胖流行背景下的心肾代谢暴露正在重塑GN-CKD的归因谱。

    本研究国际比较和人群分层结果共同指出了CKD的重点防控对象。中国和印度是3种主要病因特异性CKD的主要高负担国家；在中国，疾病负担明显向50岁及以上人群聚集，其中HTN-CKD尤其集中于≥70岁组，T2DM-CKD主要集中于50~69岁组和≥70岁组，提示中老年人群应成为CKD筛查、随访和综合干预的优先对象。

    本研究预测结果显示，2024－2035年GN-CKD归因负担总体趋于下降，而HTN-CKD和T2DM-CKD仍将持续上升，且T2DM-CKD增幅最大。这意味着未来我国CKD防控的增量压力仍将主要来自血压异常和糖脂代谢异常的持续累积。如果不能在中老年高风险人群中更早识别蛋白尿、肾功能下降及代谢共病，CKD绝对负担仍可能继续扩张。

    基于不同病因的风险结构差异，本研究认为CKD防控路径应进一步细化。对于HTN-CKD，应以≥70岁高血压患者为防控重点，强化血压达标、限盐膳食、体重管理及基层连续随访，并将尿蛋白和估算肾小球滤过率监测纳入常规慢性病管理[24-26]。对于T2DM-CKD，应以50岁及以上糖尿病或超重/肥胖人群为重点，在糖尿病前期、确诊糖尿病及早期CKD阶段分层推进体重控制、血糖达标、血压联管及肾脏保护治疗[17-21]。对于GN-CKD，则更适宜在肾小球疾病专科随访基础上加强代谢异常筛查和心肾共病管理，将高血糖、高血压和肥胖视为可干预的负担放大因素，而非简单解释为原发病因[13,25]。

    从服务体系层面看，上述路径需要依托“基层筛查-风险评估-分层转诊-长期随访”的连续管理模式。SALINE研究提示，针对CKD高风险人群开展系统性蛋白尿筛查及早期识别具有可行性[27]；我国建模研究也表明，针对一般人群和糖尿病人群的CKD筛查具有一定成本效果[28]。因此，将血压、血糖、体重和肾功能损害指标纳入同一基层管理闭环，并根据病因类型实施差异化转诊与随访策略，可能比泛化的生活方式建议更具实践价值。

    本研究的优势在于：（1）在同一分析框架下系统分析了T2DM-CKD、HTN-CKD和GN-CKD的长期变化、国际差异、人群分布及未来趋势；（2）在描述危险因素排序的基础上，进一步引入EAPC和8项危险因素内部构成比，从趋势变化和风险结构2个层面深化分析了归因负担；（3）从“病因-风险-人群-时间”多个维度提出了更具针对性的防控线索。局限性在于：（1）GBD数据属于模型估计结果，本研究结果仍受原始资料质量和模型设定影响；（2）本研究EAPC基于1990－2023年逐年ASDR的对数线性回归估计，能够反映整体平均变化速度，但未进行Joinpoint回归分析，因此不能识别潜在转折点或报告基于Joinpoint回归模型获得的分段年度变化百分比及平均年度变化百分比；（3）GBD比较风险评估框架对不同危险因素进行独立归因估计，未显式处理危险因素间的交互作用与共线性，因此不同危险因素归因负担可能存在重叠，本研究未对其进行简单加总，构成比仅反映纳入的8项危险因素内部的相对结构；（4）ARIMA预测反映的是既有趋势延续情景，未纳入未来政策变化、治疗进步及突发公共卫生事件的影响。

    综上所述，1990－2023年中国归因于8项代谢与生活方式相关危险因素的3种主要病因特异性CKD的绝对负担均呈扩张态势，但风险结构、重点人群和未来走向存在明显差异。HTN-CKD归因始终以高收缩压为核心，T2DM-CKD长期受高空腹血糖和高BMI主导，而GN-CKD归因则表现为专科疾病病因背景下多种心肾代谢相关危险因素并存。未来防控应重点面向50岁及以上人群，围绕HTN-CKD的“血压-限盐-体重”、T2DM-CKD的“血糖-体重-肾脏”以及GN-CKD的“专科随访-代谢筛查-共病管理”实施分病因、分层级的精准干预。

  • 图  1   1990年与2023年传统金砖国家归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY比较

    Fig.  1   Comparison of DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in traditional BRICS countries in 1990 and 2023

    The numbers in the cells indicate the within-panel ranking of risk factors for each country according to attributable DALY, from rank 1, the highest burden, to rank 8, the lowest burden. DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.

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    图  2   1990年与2023年传统金砖国家归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY构成比比较

    Fig.  2   Comparison of proportion of DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in traditional BRICS countries in 1990 and 2023

    DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.

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    图  3   1990－2023年中国不同性别人群归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY

    Fig.  3   DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors by gender stratification in China from 1990 to 2023

    DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.

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    图  4   2023年中国不同年龄段人群归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY

    Fig.  4   DALY of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in different age groups in China in 2023

    DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.

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    图  5   2024－2035年中国归因于8项代谢与生活方式相关危险因素的3种主要病因特异性慢性肾脏病的DALY预测趋势

    Fig.  5   Projected DALY trends of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in China from 2024 to 2035

    The red solid line represents observed DALY from 1990 to 2023, the yellow solid line represents projected DALY from 2024 to 2035, the semi-transparent yellow band represents the 95% confidence interval, and the gray dashed line marks the start of the projection period. DALY: Disability-adjusted life year; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus.

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    表  1   1990年与2023年中国3种主要病因特异性慢性肾脏病归因于8项代谢与生活方式相关危险因素的DALY、ASDR及EAPC

    Table  1   DALY, ASDR, and EAPC of 3 major etiology-specific chronic kidney diseases attributable to 8 metabolic and lifestyle-related risk factors in China in 1990 and 2023

    Risk factor 1990 2023 EAPC (95%CI)/%
    DALY (95%UI)/ (person-year) ASDR (95%UI)/(×10－5) DALY (95%UI)/ (person-year) ASDR (95%UI)/(×10－5)
    GN-CKD
      High fasting plasma glucose 94 410 (11 290, 218 708) 9.01 (1.01, 21.68) 77 872 (9 176, 186 703) 3.75 (0.47, 8.80) －3.98 (－4.44, －3.53)
      High systolic blood pressure 17 279 (0, 94 999) 2.01 (0.00, 10.86) 53 925 (6, 195 360) 2.36 (0.00, 8.89) －0.85 (－1.26, －0.45)
      High body mass index 12 468 (141, 55 109) 1.17 (0.01, 5.17) 27 138 (673, 73 829) 1.24 (0.03, 3.56) －1.24 (－1.65, －0.84)
      Low physical activity 327 (2, 1 509) 0.04 (0.00, 0.21) 961 (33, 4 381) 0.05 (0.00, 0.20) －0.73 (－1.15, －0.30)
      Diet low in fruits 7 508 (51, 33 342) 0.81 (0.01, 3.66) 14 874 (194, 48 623) 0.67 (0.01, 2.26) －1.87 (－2.25, －1.49)
      Diet low in vegetables 2 296 (2, 12 350) 0.27 (0.00, 1.43) 1 166 (4, 5 268) 0.05 (0.00, 0.24) －5.91 (－6.55, －5.27)
      Diet high in sodium 7 083 (0, 47 002) 0.79 (0.00, 5.32) 19 967 (1, 98 786) 0.87 (0.00, 4.44) －1.00 (－1.39, －0.62)
      Diet low in whole grains 1 840 (2, 11 349) 0.17 (0.00, 1.02) 1 421 (9, 7 324) 0.07 (0.00, 0.36) －4.18 (－4.77, －3.58)
    HTN-CKD
      High fasting plasma glucose 48 587 (4 054, 130 294) 7.23 (0.89, 17.84) 127 575 (24 793, 279 861) 5.93 (1.25, 12.75) －0.09 (－0.31, 0.12)
      High systolic blood pressure 317 746 (143 504, 489 909) 43.73 (20.38, 67.53) 676 130 (386 310, 887 021) 30.23 (17.22, 39.77) －0.60 (－0.85, －0.34)
      High body mass index 73 620 (26 773, 142 105) 8.36 (3.06, 16.17) 205 238 (92 560, 355 460) 9.13 (4.07, 15.80) 0.69 (0.42, 0.96)
      Low physical activity 491 (5, 2 331) 0.12 (0.00, 0.46) 2 454 (100, 9 246) 0.12 (0.01, 0.46) 0.55 (0.26, 0.84)
      Diet low in fruits 122 593 (61 061, 199 952) 15.91 (8.00, 26.12) 179 310 (96 474, 260 672) 8.11 (4.27, 11.72) －1.52 (－1.78, －1.25)
      Diet low in vegetables 44 506 (11 852, 85 497) 6.30 (1.82, 11.73) 18 107 (3 534, 45 493) 0.84 (0.16, 2.16) －5.20 (－5.93, －4.47)
      Diet high in sodium 140 798 (30 925, 290 101) 17.42 (3.45, 36.88) 219 747 (55 272, 441 655) 9.55 (2.30, 19.45) －1.27 (－1.51, －1.03)
      Diet low in whole grains 981 (2, 5 842) 0.15 (0.00, 0.84) 2 994 (44, 11 441) 0.14 (0.00, 0.52) 0.38 (0.07, 0.68)
    T2DM-CKD
      High fasting plasma glucose 604 036 (415 698, 828 929) 72.09 (50.42, 98.80) 1 041 016 (799 849, 1 296 046) 44.30 (34.31, 55.25) －1.33 (－1.45, －1.20)
      High systolic blood pressure 34 821 (0, 181 435) 4.31 (0.00, 22.64) 121 282 (4, 407 929) 5.07 (0.00, 17.20) 0.47 (0.29, 0.64)
      High body mass index 169 921 (65 952, 317 321) 18.70 (7.09, 34.95) 407 874 (175 697, 706 244) 17.20 (7.40, 29.77) －0.24 (－0.41, －0.07)
      Low physical activity 40 523 (13 372, 73 963) 5.08 (1.67, 9.28) 78 272 (30 149, 132 659) 3.35 (1.30, 5.72) －1.27 (－1.42, －1.12)
      Diet low in fruits 44 818 (8 750, 96 847) 5.26 (1.08, 11.65) 70 073 (16 762, 143 627) 2.96 (0.71, 6.02) －1.64 (－1.79, －1.50)
      Diet low in vegetables 8 374 (253, 27 506) 1.03 (0.04, 3.38) 3 823 (179, 15 910) 0.16 (0.01, 0.68) －5.21 (－5.88, －4.53)
      Diet high in sodium 13 505 (0, 82 534) 1.58 (0.00, 9.98) 42 558 (1, 209 138) 1.76 (0.00, 8.65) 0.34 (0.14, 0.54)
      Diet low in whole grains 38 372 (10 639, 72 603) 4.46 (1.21, 8.54) 53 859 (15 571, 101 849) 2.29 (0.66, 4.30) －1.89 (－2.02, －1.77)
    DALY: Disability-adjusted life year; ASDR: Age-standardized DALY rate; EAPC: Estimated annual percentage change; GN-CKD: Chronic kidney disease due to glomerulonephritis; HTN-CKD: Chronic kidney disease due to hypertension; T2DM-CKD: Chronic kidney disease due to type 2 diabetes mellitus; 95%UI: 95% uncertainty interval; 95%CI: 95% confidence interval.
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  • 收稿日期:  2026-03-18
  • 接受日期:  2026-05-11

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