1、急性腎損傷的診斷與治療,中山大學(xué)附屬第一醫(yī)院腎內(nèi)科,毛海萍,余學(xué)清,Outline,?,急性腎損傷的新概念,?,急性腎損傷的分期,?,急性腎損傷的生物學(xué)標(biāo)志物,?,急性腎損傷的替代治療,?,治療時機,?,治療方式,?,治療劑量,?,總結(jié),急性腎損傷與急性腎衰竭,(ARF),目前，國際腎臟病和急救醫(yī)學(xué)界將,ARF,改為急性,腎損傷（,Acute Kidney Injury, AKI,）。,AKI,覆蓋的腎損傷,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006,Biesen WV et al. CJASN. 2006,GFR,正常,伴腎臟損傷的標(biāo)志物改變

2、,GFR,開始,下降,GFR,明顯,異常,既往,ARF,的診斷標(biāo)準(zhǔn),混亂而多種多樣；,2003,年,Mehta,等在文獻中發(fā)現(xiàn),16,種；,2002,年,Kellum,等在文獻中發(fā)現(xiàn),35,種；,共同特點：,?,溶質(zhì)的清除：常用血肌酐，有時用尿或血尿素氮；,?,24,小時尿量：,480500ml/24h,，或,0.5ml/kg/h,；,?,區(qū)別慢性腎臟病基礎(chǔ)上的,AKI,：排除或單獨標(biāo)準(zhǔn)。,Mehta RL, et al. J Am Soc Nephrol 14:2178-2187, 2003,Kellum JA et al. Curr Opin Crit Care. 8:509-514, 2

3、002,2004,年,560,個中心,AKI,標(biāo)準(zhǔn),Ricci Z, et al. Nephrol Dial Transplant 2006;21:690-696,AKI,的界定值？,血肌酐,0.5 mg/L;,血肌酐,1.0 mg/L;,血肌酐,25%;,血肌酐,50%;,血肌酐,25%,2.5 mg/L;,血肌酐,1mg/dl/2d;,Death,AKI,是患者死亡的獨立危險因素,Complications,Normal,Increased,risk,Kidney,failure,Damage,?,GFR,住院病人,AKI,的年齡分布,0.0%,0.5%,1.0%,1.5%,2.0%,2.

4、5%,3.0%,3.5%,4.0%,0-44,45-64,65-74,75+,1982,1992,2002,From National Center For Health Statistics, National Hospital Discharge Survey,血肌酐與患者預(yù)后,Chertow GM, et al. J Am Soc Nephrol 2005; 16: 3365-3370,?,2005,年,9,月在阿姆斯特丹召開了,AKI,的國際研討會。,?,提出了,AKI,的定義、診斷和分,期的統(tǒng)一標(biāo)準(zhǔn)。,AKI,的定義,AKI,是指不超過,3,個月的腎臟結(jié)構(gòu),或功能的異常，包括血、尿、

5、組織,檢測或影像學(xué)方面的腎損傷標(biāo)志物,的異常。,AKIN Organizing Committee 2005,Hoste EA et al. Critical Care.10(3):1-10,2006,Rabb H. J Am Soc Nephrol 17:604-606,2006,AKI,的診斷標(biāo)準(zhǔn),腎功能在,48,小時內(nèi)突然降低：,?,Scr,升高絕對值,0.3mg/dl,（,26.5umol/L,）,;,?,Scr,較前升高,50%,；,?,持續(xù),6,小時以上尿量,0.5ml/kg/h,。,符合下列條件之一：,單獨應(yīng)用尿量的改變作為診斷標(biāo)準(zhǔn)時，需要除外尿,路梗阻或其他可導(dǎo)致尿量減少的原因

6、。,AKIN Organizing Committee 2005,Outline,?,急性腎損傷的新概念,?,急性腎損傷的分期,?,急性腎損傷的生物學(xué)標(biāo)志物,?,急性腎損傷的替代治療,?,治療時機,?,治療方式,?,治療劑量,?,總結(jié),AKI,的分期標(biāo)準(zhǔn),?,RIFLE,標(biāo)準(zhǔn),?,2005,年阿姆斯特丹,AKI,合作,研討會標(biāo)準(zhǔn),AKI,合作研討會標(biāo)準(zhǔn),I,II,III,Increased creatinine x0.5,OR 0.3mg/dl,UO .3ml/kg/h,x 24 hr or,Anuria x 12 hrs,UO .5ml/kg/h,x 12 hr,UO .5ml/kg/h,x

7、 6 hr,Increased creatinine x2,Increase creatinine x3,or creatinine,?,4mg/dl,(Acute rise of,?,0.5 mg/dl),High,Sensitivity,High,Specificity,AKI,分期標(biāo)準(zhǔn)的特點,?,明確了診斷,AKI,的時間窗，即,48,小時；,?,提高了,AKI,診斷的敏感性，即血肌酐輕微,升高,0.3 mg/dl,；,?,既包含血肌酐絕對值改變，也包含相對于,年齡、性別、體重指數(shù)、既往腎功能狀況,等差異的相對值改變；,?,尿量標(biāo)準(zhǔn)仍然是診斷,AKI,的重要指標(biāo)。,Outline,?,急

8、性腎損傷的新概念,?,急性腎損傷的分期,?,急性腎損傷的生物學(xué)標(biāo)志物,?,急性腎損傷的替代治療,?,治療時機,?,治療方式,?,治療劑量,?,總結(jié),AKI,的生物學(xué)標(biāo)志物,Scr,：年齡、性別和種族的影響,?,兩性霉素,B,引起的,ARF,：男,:,女,2:1,男性是,AKI,的危險因素,?,Bates DW, et al. Clin Infect Dis 32: 686,693;2001,?,不能區(qū)分腎損傷的性質(zhì)和類型,?,不能明確腎小球或小管病變的位置和程度,Scr,不是評估腎功能的準(zhǔn)確指標(biāo),性別,年齡,肌肉,種族,Scr 110,mol/L =,110,mol/L,Ccr 120,ml/

9、min,56,ml/min,Scr,不是判斷腎功能損害的敏感指標(biāo),Cystatin C,與,AKI,0,50,100,150,200,250,R-day3,R-day2,R-day1,R-day0,0,50,100,150,200,250,300,I-day2,I-day1,I-day0,Scr,Cys C,Herget-Rosenthal S et al. Kidney Int. 2004 ;66(3):1115-22,Cystatin C,升高,早于,Scr,升高,1,2,天,腎小管損傷的生物學(xué)標(biāo)志物：,?,腎損傷因子,-1( KIM-1),?,半胱氨酸、肝素結(jié)合蛋白,( Cyr61),?

10、,中性粒細(xì)胞明膠酶相關(guān)蛋白,(NGAL),?,IL-18,AKI,的影像學(xué)檢查,應(yīng)用新型造影劑的核磁共振檢查,?,提供腎內(nèi)血流動力學(xué)變化的信息,?,近端小管功能紊亂的水平和程度,?,腎內(nèi)炎癥情況,Prasad PV,et al. J Magn Reson Imaging, 2001;13: 744,747,Kobayashi H,et al. Kidney Int 2002;61: 1980-1985,Jo S, et al. Kidney Int 2003;64: 43,51,新型理想的,AKI,標(biāo)志物,?,在血肌酐升高之前可診斷,AKI,；,?,對,AKI,的病情輕重能進行分層診斷；,?,

11、有助于判斷,AKI,的預(yù)后。,Outline,?,急性腎損傷的新概念,?,急性腎損傷的分期,?,急性腎損傷的生物學(xué)標(biāo)志物,?,急性腎損傷的替代治療,?,治療時機,?,治療方式,?,治療劑量,?,總結(jié),AKI,進行,RRT,治療的指征,?,少尿,(,尿量,200ml/12h),；,?,無尿,(,尿量,50ml/12h),；,?,高鉀血癥,(,血鉀,6.5mmol/L),；,?,嚴(yán)重酸中毒,( pH,7.0,）；,?,155 mmol/L,血鈉,120 mmol/L,；,?,血尿素氮,30mmol/L,；,?,尿毒癥性腦病、心包炎；,?,水負(fù)荷過重。,Lameire N. Acute Renal

12、Failure. Lancet 2005;365:417-430,AKI,接受血液透析的時機,B,U,N,p,r,e,D,i,a,l,y,s,i,s,(,m,g,/,d,L,),S,u,r,v,i,v,a,l,(,%,),n,E,a,r,l,y,L,a,t,e,E,a,r,l,y,L,a,t,e,P,a,r,s,o,n,s,e,t,a,l,L,a,n,c,e,t,1,9,6,1,;,1,:,1,2,9,-,1,3,4,3,3,1,2,0,-,1,5,0,2,0,0,7,5,1,2,F,i,s,c,h,e,r,e,t,a,l,S,u,r,g,G,y,n,e,c,o,l,O,b,s,t,e,t,1

13、,9,6,6,;,1,2,3,:,1,0,1,9,-,1,0,2,3,1,6,2,1,5,0,2,0,0,4,3,2,6,K,l,e,i,n,k,n,e,c,h,t,e,t,a,l,K,i,d,n,e,y,I,n,t,1,9,7,2,;,1,:,1,9,0,-,1,9,6,5,0,0,9,3,1,6,3,7,1,5,8,創(chuàng)傷合并,AKI,進行,CVVH,的時機,39 %,20 %,0%,10%,20%,30%,40%,50%,60%,S,u,r,v,i,v,a,l,BUN 60 mg/dL,BUN 60 mg/dL,Gettings LG, et al: Intensive Care Med

14、1999; 25:805-813,(Mean: 42.6,12.9),(Mean: 94.5,28.3),n=41,n=59,心臟外科術(shù)后合并,AKI,進行,CVVH,時機,22%,23.5%,43%,55.5%,0%,10%,20%,30%,40%,50%,60%,M,o,r,t,a,l,i,t,y,Early,Late,Elahi,Demirkilic,Elahi MM, et al: Eur J Cardiothorac Surg 2004; 26: 1027-1031,Demirkilic U, et al: J Card Surg 2004; 19: 17-20,n=28,n=36,

15、n=27,n=34,BUN 84 mg/dL,Cr 2.8 mg/dL, or,Potassium 6 mEq/L,UOP 100 mL for 8 hours,Cr 5.0 mg/dL, or,Potassium 5.5 mEq/L,AKI,進行,RRT,的時機,:,PICARD Study Data,BUN,76 mg/dL,(n=122),BUN 76 mg/dL,(n=121),Mean BUN,47.4 mg/dL,114.9 mg/dL,p0.0001,Mean Creatinine,3.4 mg/dL,4.7 mg/dL,p0.0001,Failed Organ Systems,

16、4 (IQR: 3-4),3 (IQR: 2-4),p=0.008,Sepsis,37%,46%,p=0.14,Initial RRT with CRRT,69%,43%,p0.001,Survival,day 14,day 28,80%,65%,75%,59%,p=0.09,Adjusted mortality risk,adjusted for covariates,adjusted for propensity score,adjusted for both covariates and propensity,1.85 (95% CI: 1.16-2.96),2.07 (95% CI:

17、1.30-3.29),1.97 (95% CI: 1.21-3.20),Liu K et al. Clin J Am Soc Nephrol 2006; 1: e-pub,Outline,?,急性腎損傷的新概念,?,急性腎損傷的分期,?,急性腎損傷的生物學(xué)標(biāo)志物,?,急性腎損傷的替代治療,?,治療時機,?,治療方式,?,治療劑量,?,總結(jié),IHD,與,CRRT,治療,AKI,Odds Ratio,of Survival,95%,CI,Renal Replacem,ent Therapy,Interm,ittent,Continuous,1.02,0.88,0.68,1.54,0.56,1.37

18、,SAPS II 50 on adm,ission,0.35,0.21,0.59,Oliguria,0.27,0.16,0.44,No underlying disease,3.62,1.64,7.95,Hepatic dysfunction,3.46,1.56,7.67,Adm,ission from,hospital or ED,0.50,0.31,0.80,Days from,adm,ission to episode of ARF 0,0.53,0.32,0.89,Ischem,ic ARF,0.35,0.19,0.65,Cardiovascular dysfunction,0.45,

19、0.27,0.77,Infection,0.62,0.38,1.00,M,ultiple episodes of ARF,0.37,0.14,0.98,Guerin C, et al. Intensive Care Med 2002; 28:1411-1418,IHD,與,CRRT,治療,AKI:,HEMODIAFE Study,Vinsonneau C, et al: Lancet 2006; 368:379-385,C,R,R,T,I,H,D,p,v,a,l,u,e,N,8,4,8,2,A,P,A,C,H,E,I,I,S,c,o,r,e,2,3,.7,2,5,.5,N,S,A,P,A,C,

20、H,E,I,I,I,S,c,o,r,e,9,6,.4,8,7,.7,0,.0,4,5,I,C,U,M,o,r,t,a,l,i,t,y,5,9,.5,%,4,1,.5,%,0,.0,2,H,o,s,p,i,t,a,l,M,o,r,t,a,l,i,t,y,6,5,.5,%,4,7,.6,%,0,.0,2,I,C,U,L,e,n,g,t,h,o,f,S,t,a,y,1,5,.1,d,a,y,s,1,6,.7,d,a,y,s,N,S,R,e,n,a,l,R,e,c,o,v,e,r,y,3,4,.9,%,3,3,.3,%,N,S,IHD,與,CRRT,治療,AKI,Mehta R, et al: Kid

21、ney Int 2001; 60:1154-1163,IHD,與,CRRT,治療,AKI:,腎功能的恢復(fù),CRRT,IHD,N,survived,recovered,N,survived,recovered,Mehta,et al,64,22,16,67,34,20,Manns,et al.,178,50,40,83,47,30,Jacka,et al.,65,24,21,28,14,5,Total,307,96,77,178,95,55,80.2%*,57.9%*,Mehta R, et al: Kidney Int 2001; 60:1154-1163,Manns B, et al. Cr

22、it Care Med 2003; 31:449-455,Jacka MJ, et al. Can J Anesth 2005; 52:327-332,*percentage of survivors,IHD,與,CRRT,治療,AKI,0%,20%,40%,60%,80%,100%,病情程度,死,亡,率,IHD,CRRT,腹膜透析和,CVVH,治療,AKI,Phu NH, et al: N Engl J Med 2002; 347:895-902,Outline,?,急性腎損傷的新概念,?,急性腎損傷的分期,?,急性腎損傷的生物學(xué)標(biāo)志物,?,急性腎損傷的替代治療,?,治療時機,?,治療方式,

23、?,治療劑量,?,總結(jié),血液透析治療,AKI,的劑量,Paganini EP, et al: Am J Kidney Dis 1996; 28 (suppl 3):S81-S89,Schiffl H, et al. N Engl J Med 2002; 346:305-310,Alternate-Day,Hemodialysis,Daily,Hemodialysis,P value,Mortality,46%,28%,0.01,Duration of ARF,(days),16,6,9,2,0.001,血液透析治療,AKI,的頻度,預(yù)后,Schiffl H, et al. N Engl J Med 2002; 346:305-310,A,lte,rn,a,te,-D,a,y,H,e,m,o,d,ia,ly,sis,D,a,ily,H,e,m,o,d,ia,ly,sis,D,u,ra,tio,n,(h,rs),3,.4,0,.5,3,.3,0,.4,B,F,R,(m,L,/m,in,),2,4,3,2,5,2,4,8,4,5,D,o,se,(K,t/V,),P,re,sc,rib,e,d,D,e,liv,e,re,d,W,e,e,k,ly,1,.2,1,0,.0,9,0,.9,4,0,.1,