# 追加：第 16 节第 13、14 条（慢性肾病筛查、结肠癌术后运动）

2026-10-14。主任务列的两个候选，追加在第 16 节末尾，没插中间。本节加完 14 条，不到 20 条，不补导览。

## 查重与四问
- 全书 grep「尿白蛋白」「肾小球」「肌酐」「慢性肾病」「KDIGO」：没有讲肾病筛查的条目。只有第 1 节 PrEP 条提到开药前查肾功能，第 9 节卖肾，都不是同一件事。
- 是否并进第 7 条（查眼底和脚）：没并。第 7 条标题只讲糖尿病的眼和脚，往里加肾要改标题，而肾病筛查还管高血压病人，人群不同。所以单开第 13 条，第 7 条备注末尾加了一句指路。第 3 条（复查记本子）讲的是记录方式，不是查哪一项，也没并。
- 全书 grep「结肠癌」「结直肠癌」「CHALLENGE」「Courneya」：只有第 1 节第 19 条结直肠癌筛查，和第 16 节第 4 条备注里提到结直肠癌病人用偏方，都不是术后运动。
- 四问：① 中国每年结直肠癌新发病人多，慢性肾病约 8200 万人，都是普通读者会碰上的；② 知晓率只有 10%，糖尿病病人里查过的只有 27%；术后多数人以为该静养，不知道有随机试验支持运动；③ 动作是新的；④ 都有原始文献。

## 第 13 条 慢性肾病筛查

### Wang L 2023, JAMA Internal Medicine（第六次中国慢性病及危险因素监测）
- DOI：<https://doi.org/10.1001/jamainternmed.2022.6817>，摘要从 Europe PMC 取（PMC9941971）。
- 「of the 176 874 adults 18 years and older with measurements of eGFR and urine albumin-to-creatinine ratio in 2018 to 2019」
- 「The estimated prevalence of CKD, impaired kidney function, and albuminuria were 8.2%, 2.2%, and 6.7%, respectively.」
- 「Among the adults with CKD, 73.3%, 25.0%, and 1.8% were at stage 1 to 2, 3, and 4 to 5, respectively, and the awareness of CKD was 10.0%.」
- 「This cross-sectional study found a weighted estimated of 82 million adults with CKD in China in 2018 to 2019.」
- 主任务点名的 Zhang L 2012 Lancet（doi:10.1016/S0140-6736(12)60033-6）：摘要里有患病率 10.8%、约 1.195 亿人，但知晓率不在摘要里，Lancet 全文页本机取不到（只返回约 5.8 KB 的壳页）。所以改用更新的 2018–2019 全国监测，Zhang 2012 没引。

### Shi L 2024, JMIR Public Health and Surveillance（IMPROVE 研究）
- DOI：<https://doi.org/10.2196/54429>（PMC11399742）
- 「A national study from December 2021 to September 2022 enlisted 9672 participants with type 2 diabetes from 45 hospitals that had endocrinology departments.」
- 「The prevalence, screening, and awareness rates of CKD among patients with type 2 diabetes were 31% (2997/9672), 27% (810/2997), and 54.8% (5295/9672), respectively.」
- 正文写成「这 2997 人里，以前查过肾病的只有 27%」，取的是 810/2997 这个分母。知晓率 54.8% 的分母是全部糖尿病病人，口径不同，没写进正文。

### KDIGO 2024 CKD 指南
- DOI：<https://doi.org/10.1016/j.kint.2023.10.018>，Crossref 核到 Kidney International 105(4) S117–S314。全文 PDF 从 kdigo.org 下载（KDIGO-2024-CKD-Guideline.pdf），英文 pdftotext 能逐字取。
- 「Practice Point 1.1.1.1: Test people at risk for and with chronic kidney disease (CKD) using both urine albumin measurement and assessment of glomerular filtration rate (GFR).」
- 「Practice Point 1.1.1.2: Following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR), repeat tests to confirm presence of CKD.」
- 「The highest priority conditions for CKD detection are hypertension, diabetes, and CVD, including heart failure. For diabetes, the ADA and KDIGO recommend annual screening of people with diabetes for CKD.」
- 高血压病人的筛查间隔，全文没有找到固定频率，所以标题写「有高血压的也要查」，没写「每年」。

### ADA Standards of Care 2026, Section 11
- DOI：<https://doi.org/10.2337/dc26-S011>，Diabetes Care 49(Suppl 1) S246–S260（Crossref）。全文从 PMC 页面取（PMC12690176），Europe PMC 的 fullTextXML 接口返回 500。
- 「11.1a Assess kidney function with random urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) at least annually in people with type 1 diabetes with duration of ≥5 years and in all people with type 2 diabetes regardless of treatment. B」
- 「11.6a In nonpregnant people with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker (ARB) is recommended for those with moderately increased albuminuria (UACR 30–299 mg/g creatinine) B and is strongly recommended for those with severely increased albuminuria (UACR ≥300 mg/g creatinine) and/or eGFR <60 mL/min/1.73 m2 ...」

### Heerspink 2020 NEJM（DAPA-CKD）
- DOI：<https://doi.org/10.1056/NEJMoa2024816>，摘要从 Europe PMC 取。
- 「We randomly assigned 4304 participants with an estimated glomerular filtration rate (GFR) of 25 to 75 ml per minute per 1.73 m2 ... and a urinary albumin-to-creatinine ratio ... of 200 to 5000」
- 「Over a median of 2.4 years, a primary outcome event occurred in 197 of 2152 participants (9.2%) in the dapagliflozin group and 312 of 2152 participants (14.5%) in the placebo group (hazard ratio, 0.61; 95% confidence interval [CI], 0.51 to 0.72」
- 「Death occurred in 101 participants (4.7%) in the dapagliflozin group and 146 participants (6.8%) in the placebo group (hazard ratio, 0.69; 95% confidence interval [CI], 0.53 to 0.88; P = 0.004).」
- 「The effects of dapagliflozin were similar in participants with type 2 diabetes and in those without type 2 diabetes.」

### 国家基本公共卫生服务规范
- 主任务要求以原文为准。gov.cn 政策库用 `searchfield=title` 搜「基本公共卫生服务规范」无结果；卫健委官网的第三版规范是中文 PDF，本机 pdftotext 取不出中文。核不到原文，正文不写「基本公卫免费查不查这一项」。

### 定级
- 证据等级 B：筛查本身没有随机试验比过死亡；少死的数字来自已经查出尿蛋白偏高、再吃药的人。
- 收益量级「中」凭判断：收益栏里死亡 HR 0.69 机械套是「大」，但那是查出来以后吃药这一步的效果，只落在查出异常的那部分人身上，所以降一档。
- 成本「钱=少」：一次尿白蛋白肌酐比加血肌酐，属于常规化验，正文没写具体价格（各地收费不同，没查到统一官方价）。

## 第 14 条 结肠癌术后运动

### Courneya 2025 NEJM（CHALLENGE，CCTG CO.21）
- DOI：<https://doi.org/10.1056/NEJMoa2502760>，393(1):13–25，摘要从 Europe PMC 取（PMID 40450658）。NEJM 全文页本机取不到。
- 「In this phase 3, randomized trial conducted at 55 centers, we assigned patients with resected colon cancer who had completed adjuvant chemotherapy to participate in a structured exercise program (exercise group) or to receive health-education materials alone (health-education group) over a 3-year period. The primary end point was disease-free survival.」
- 「a total of 889 patients underwent randomization to the exercise group (445 patients) or the health-education group (444 patients). At a median follow-up of 7.9 years, disease-free survival was significantly longer in the exercise group than in the health-education group (hazard ratio for disease recurrence, new primary cancer, or death, 0.72; 95% confidence interval [CI], 0.55 to 0.94; P = 0.02). The 5-year disease-free survival was 80.3% in the exercise group and 73.9% in the health-education group」
- 「Results support longer overall survival in the exercise group than in the health-education group (hazard ratio for death, 0.63; 95% CI, 0.43 to 0.94). The 8-year overall survival was 90.3% in the exercise group and 83.2% in the health-education group」
- 「Musculoskeletal adverse events occurred more often in the exercise group than in the health-education group (in 18.5% vs. 11.5% of patients).」
- 「... resulted in significantly longer disease-free survival and findings consistent with longer overall survival.」备注「总死亡是次要结果……和活得更长相符」据此写。

### ClinicalTrials.gov NCT00819208（方案与入组条件，API v2 取）
- 入组：「Completely resected histologically confirmed adenocarcinoma of the colon」「High-risk stage II disease ...」「Stage III disease ...」「Chemotherapy must have been completed (i.e. last dose received) a minimum of 60 days and a maximum of 180 days prior to registration.」「Current physical activity levels do not meet the recommended guidelines (≥ 150 minutes of moderate-to-vigorous or ≥ 75 minutes of vigorous physical activity/week)」「these imaging tests must not show evidence of metastatic or locally-recurrent colon cancer」「No rectal cancer」；入组前要做次极量运动测试或 6 分钟步行测试。
- 干预：「Part I (intensive intervention for 6 months): Patients undergo 12 mandatory biweekly face-to-face behavior support sessions combined with 12 mandatory supervised physical activity sessions to increase their physical activity goal by 10 metabolic equivalent task (MET) hours/week.」「Part II (reduced intervention for months 6-12): Patients undergo 12 mandatory biweekly face-to-face or telephone behavior support sessions ...」「Phase 3: Minimal intervention for months 12-36」
- 「Most patients are likely to choose a walking program however any PA of at least moderate intensity level is acceptable.」正文写成「方案预计多数人会选走路」，这是方案里的预期，不是结果。

### Courneya 2016 CEBP（一年可行性结果）
- DOI：<https://doi.org/10.1158/1055-9965.EPI-15-1267>
- 「The SEP group reported an increase in recreational PA of 15.6 MET-hours/week compared with 5.1 MET-hours/week in the HEM group」

### Chan 2026 JCO（费用分析）
- DOI：<https://doi.org/10.1200/JCO-26-00765>，44(22):2130–2139（Crossref）。
- 「despite an up-front cost of $2,917 (CAD)/participant to provide the SEP, the SEP strategy (total cost: $31,957 (CAD)/participant) was dominant over HEM (total cost: $33,546 (CAD)/participant), being less costly (-$1,589/participant)」；基线是加拿大公共支付方角度、5 年。

### 定级
- 证据等级 A：大型多中心随机试验，有具体 HR。只有一项试验，但没找到反方试验，没标争议。
- 收益量级「大」：无病生存降约 28%、死亡降约 37%，按死亡率口径 ≥20% 机械套。
- 成本「钱=少」：国内没有同款成套项目，按医院运动处方或康复科评估的挂号检查费算；试验里的 2917 加元是加拿大整套指导费用，没换算成人民币写进成本栏。「时间=中」：每周多出 10 个代谢当量小时的运动，是每周小时级。「毅力=是」：要坚持三年。
- 主任务提的「其他癌种的观察性证据」没写：不在本条动作范围内，备注只写了「不能直接套到别的癌症和晚期病人身上」。

## 自检
- `node tools/check-plain.mjs`：752 条不合格 0 条。
- `node tools/check-refs.mjs --check`：1732 处全部通过。