急性肾损伤AKI的诊断与治疗.ppt

1、急性肾损伤的诊断与治疗,中山大学附属第一医院肾内科,毛海萍,余学清,Outline,?,急性肾损伤的新概念,?,急性肾损伤的分期,?,急性肾损伤的生物学标志物,?,急性肾损伤的替代治疗,?,治疗时机,?,治疗方式,?,治疗剂量,?,总结,急性肾损伤与急性肾衰竭,(ARF),目前，国际肾脏病和急救医学界将,ARF,改为急性,肾损伤（,Acute Kidney Injury, AKI,）。,AKI,覆盖的肾损伤,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006,Biesen WV et al. CJASN. 2006,GFR,正常,伴肾脏损伤的标志物改变

2、,GFR,开始,下降,GFR,明显,异常,既往,ARF,的诊断标准,混乱而多种多样；,2003,年,Mehta,等在文献中发现,16,种；,2002,年,Kellum,等在文献中发现,35,种；,共同特点：,?,溶质的清除：常用血肌酐，有时用尿或血尿素氮；,?,24,小时尿量：,480500ml/24h,，或,0.5ml/kg/h,；,?,区别慢性肾脏病基础上的,AKI,：排除或单独标准。,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,个中心,AKI,标准,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,是患者死亡的独立危险因素,Complications,Normal,Increased,risk,Kidney,failure,Damage,?,GFR,住院病人,AKI,的年龄分布,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,血肌酐与患者预后,Chertow GM, et al. J Am Soc Nephrol 2005; 16: 3365-3370,?,2005,年,9,月在阿姆斯特丹召开了,AKI,的国际研讨会。,?,提出了,AKI,的定义、诊断和分,期的统一标准。,AKI,的定义,AKI,是指不超过,3,个月的肾脏结构,或功能的异常，包括血、尿、

5、组织,检测或影像学方面的肾损伤标志物,的异常。,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,的诊断标准,肾功能在,48,小时内突然降低：,?,Scr,升高绝对值,0.3mg/dl,（,26.5umol/L,）,;,?,Scr,较前升高,50%,；,?,持续,6,小时以上尿量,0.5ml/kg/h,。,符合下列条件之一：,单独应用尿量的改变作为诊断标准时，需要除外尿,路梗阻或其他可导致尿量减少的原因

6、。,AKIN Organizing Committee 2005,Outline,?,急性肾损伤的新概念,?,急性肾损伤的分期,?,急性肾损伤的生物学标志物,?,急性肾损伤的替代治疗,?,治疗时机,?,治疗方式,?,治疗剂量,?,总结,AKI,的分期标准,?,RIFLE,标准,?,2005,年阿姆斯特丹,AKI,合作,研讨会标准,AKI,合作研讨会标准,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,分期标准的特点,?,明确了诊断,AKI,的时间窗，即,48,小时；,?,提高了,AKI,诊断的敏感性，即血肌酐轻微,升高,0.3 mg/dl,；,?,既包含血肌酐绝对值改变，也包含相对于,年龄、性别、体重指数、既往肾功能状况,等差异的相对值改变；,?,尿量标准仍然是诊断,AKI,的重要指标。,Outline,?,急

8、性肾损伤的新概念,?,急性肾损伤的分期,?,急性肾损伤的生物学标志物,?,急性肾损伤的替代治疗,?,治疗时机,?,治疗方式,?,治疗剂量,?,总结,AKI,的生物学标志物,Scr,：年龄、性别和种族的影响,?,两性霉素,B,引起的,ARF,：男,:,女,2:1,男性是,AKI,的危险因素,?,Bates DW, et al. Clin Infect Dis 32: 686,693;2001,?,不能区分肾损伤的性质和类型,?,不能明确肾小球或小管病变的位置和程度,Scr,不是评估肾功能的准确指标,性别,年龄,肌肉,种族,Scr 110,mol/L =,110,mol/L,Ccr 120,ml/

9、min,56,ml/min,Scr,不是判断肾功能损害的敏感指标,Cystatin C,与,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,肾小管损伤的生物学标志物：,?,肾损伤因子,-1( KIM-1),?,半胱氨酸、肝素结合蛋白,( Cyr61),?

10、,中性粒细胞明胶酶相关蛋白,(NGAL),?,IL-18,AKI,的影像学检查,应用新型造影剂的核磁共振检查,?,提供肾内血流动力学变化的信息,?,近端小管功能紊乱的水平和程度,?,肾内炎症情况,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,标志物,?,在血肌酐升高之前可诊断,AKI,；,?,对,AKI,的病情轻重能进行分层诊断；,?,

11、有助于判断,AKI,的预后。,Outline,?,急性肾损伤的新概念,?,急性肾损伤的分期,?,急性肾损伤的生物学标志物,?,急性肾损伤的替代治疗,?,治疗时机,?,治疗方式,?,治疗剂量,?,总结,AKI,进行,RRT,治疗的指征,?,少尿,(,尿量,200ml/12h),；,?,无尿,(,尿量,50ml/12h),；,?,高钾血症,(,血钾,6.5mmol/L),；,?,严重酸中毒,( pH,7.0,）；,?,155 mmol/L,血钠,120 mmol/L,；,?,血尿素氮,30mmol/L,；,?,尿毒症性脑病、心包炎；,?,水负荷过重。,Lameire N. Acute Renal

12、Failure. Lancet 2005;365:417-430,AKI,接受血液透析的时机,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,创伤合并,AKI,进行,CVVH,的时机,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,心脏外科术后合并,AKI,进行,CVVH,时机,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,进行,RRT,的时机,:,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,?,急性肾损伤的新概念,?,急性肾损伤的分期,?,急性肾损伤的生物学标志物,?,急性肾损伤的替代治疗,?,治疗时机,?,治疗方式,?,治疗剂量,?,总结,IHD,与,CRRT,治疗,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,与,CRRT,治疗,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,与,CRRT,治疗,AKI,Mehta R, et al: Kid

21、ney Int 2001; 60:1154-1163,IHD,与,CRRT,治疗,AKI:,肾功能的恢复,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,与,CRRT,治疗,AKI,0%,20%,40%,60%,80%,100%,病情程度,死,亡,率,IHD,CRRT,腹膜透析和,CVVH,治疗,AKI,Phu NH, et al: N Engl J Med 2002; 347:895-902,Outline,?,急性肾损伤的新概念,?,急性肾损伤的分期,?,急性肾损伤的生物学标志物,?,急性肾损伤的替代治疗,?,治疗时机,?,治疗方式,

23、?,治疗剂量,?,总结,血液透析治疗,AKI,的剂量,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,血液透析治疗,AKI,的频度,预后,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,