急性肾损伤-从基础到临床课件

急性肾损伤(AKD中的若干问题重症医学科蔡晶晶肾脏结构肾皮质肾单位血液滤过肾小管和集合管肾锥体肾髓质肾小球原尿重吸收集合管肾小管周围毛细血管肾盂Meanglomerularcapillarypressure:输尿管MeanhydrostaticpressuregredientMeanpressuredrivingultratittratiProwle,J.Retal.NatRev.Nephrol,6,107-115(2019)1为什么要提出这个概念急性肾损伤·1951年,Homerwsmith首次引入了“急性肾衰竭”这一概念近年的研究表明,住院患者血肌酐的轻微改变即与不良预后相关近年来国际肾脏病及重症医学界使用急性肾损伤(acutekidneyinjury)替代急性肾衰竭住院患者血肌酐的轻微改变即与死亡风险和治疗费用相关Hospital-acquiredAKl:mortalityandcostassociatedwithselectedchangesinSCrcreaseMultivariableAreaunderIncrease(mg/dl(95%C)curvetotal画4.1(3.15.5)0.84s4880.56.5(508.5)0.86S74999.7(71-132)2.0164(10.3-26)0.83s22023AKI,acutekidneyinjury:CL,confidenceintervalOR,oddsratio;ROC,receivingoperatingcharacteristic;SCr,serumcreatinineIme/dL=88.4lumolLhertowGMetal.JAmSocNephrol2019:16:3365-3374急性肾损伤在ICU中,AKI的发病率逐年增加,急性肾损伤的严重程度和病死率密切相关AKI的发生率和死亡率IncidenceandmortalityofacutekidneyinjuryinselectedconditionsAuthorDefinitionofaklIncidenceIn-hospitalmortalityepsisSCrincreaseto2mg/dLloAkl:2492%:AKD:.missionsSCrnsefroms10toAKHD:lI%100%increaseinSCrlo23.5mg/dl(notAKIfromsepsis:74%46%ofAKIinsepsisAsepticAKl:45%sepsis/SIRS(N-2,527needfordialysis,ordoublingofsCrercutaneouscoronaryvarenzi4STelIncreaseinSCr>0.5mg/dL上31%NoAKl:06hranPCI(N-8,351IncreaseinSCr225%or20.5mg/dLAK:13%aN=758IncreaseinSCr20.5mg/dLAKI:3.3%;AKHD:0.3%AK:22%:NoAK1:1%McCulloughPCI(N-1,326)IncreaseinSCr525%AKLD.08%AKE7%AKD-D36chellCTangiographytoruleoutIncreaseinSCr>25%AK4%ofenfirecohort,Notreported122cfthosewih2sCemergencydept(N=1,2241asurementAKDo%.forcardiacIncreaseinscr>25%AKlinDMCKD:2.4%Notreported220AKinIcontast:2.1%Notreportedtoatleast1.2mg/dAKnⅣcontrast:I3%WaikarSSetal.ClinJAmSocNephrol2019:3:844-86AKI的发生率和死亡率MehtaNeedfordialysisAKI:notreportedNoAKlD:23%AKHD:43.6%PatientsundergoingCABGIncreaseinSCr<25%,25-49%wthoutvalvereplcement)50-99%,2100%N=1.391≥100%:5%125491.8orvalvularsurgwithinAKl:notreportedAKHD.1.7%Bove=pulmonarybypass,IncreaseinSCr2100%AK:34%AKID:1.9%certCABGorvalvularsurgeryIncreaseinSCr>20%withinAK:15.6%NAK:1.0%N=591AKID:1.4%AK:120%:AKD375%|N-43642AKID:1.I%0-daymortalityAKD:63.8%N2220Mangano"CABGarvaleaseinSCrof20.7mg/dN。AK:0y%loatleast2.0mg/dLAKH:142AK:19%,AD:63.8AKI的发生率和死亡率Incidenceandmortalityofacutekidneyinjuryinselectedconditions(continuedSettingDefinition]ofAKInhospitalmortalityFolwer"7Daptomycin(n=124)orDecreaseinCrClto<50mL/min,AKl,daptomycin:11%Notreportedinoriom/mnf250atbaselineAKI,gentamicin:26.3%Bates5459BN-70AK:149(164receivedliposomal)least2.0mg/dL(severe:peckAK:54%ationSCratleast3.0mg/dL)IncreaseinsCrcf≥l00%AK:53%A:5%%aspergillosis(N=2391AKID:76%0eehey1Aminoglycosides(N-2431IncreaseinSCrcf0.5mg/dLNotreportedand100%overbaselineSmita3GentamicinandAK:19.2%NotreportedIncreaseinSCrcf220%6AK:13%bothgroups)NotreportedAKHD:notreporledIncreaseinSCrof220%AKE:1.2%6