重症患者之急性肾损伤

doi:10.3877/cma.j.issn.2096-1537.2018.02.004

重症监护病房中，急性肾损伤的发生率逐年增加，台湾地区全民健康保险研究数据库显示ICU的患者约有10%需要肾脏替代治疗。造成肾损伤主要的原因为脓毒症及低血容积休克，静脉输液补充血管内容积及维持稳定血压及肾灌注为最基本的治疗。由于利尿剂在防止或治疗肾损伤中的角色已淡出，肾脏替代疗法应在无尿期时尽早实施。连续性肾脏替代治疗（CRRT），可以避免洗肾时的低血压发生，持续性低效率每日透析（SLEDD）是一种复合型治疗，结合了CRRT血流动力状态稳定的优点，也具备间歇性肾脏替代治疗节省人力与治疗时间的好处。一个多专科团队能及时矫正即有的疾病，充分的血流动力及营养支持，早期的肾脏替代治疗，可防止多重器官衰竭发生，改善患者的结果。

关键词: 急性肾损伤, 连续性肾脏替代治疗, 持续性低效率每日透析

The incidence of acute kidney injury (AKI) is increasing and up to 10% of total ICU patients need renal replacement therapy. The major causes of AKI are sepsis and hypovolemic shock. Adequate intravascular fluid and stable blood pressure to maintain renal perfusion remain the basis for the managements of AKI. Since the efficacy of diuretics was challenged, renal replacement therapy should be implemented at the early phase of anuria. Continuous renal replacement therapy (CRRT) is preferred to avoid of intradialytic hypotension. Either continuous veno-venous hemofiltration (CVVH) or hybrid therapy using sustained low efficiency daily dialysis (SLEDD) is good choice for the hemodynamic unstable sepsis patients. A multi-disciplinary team approach to correct underlying disease, optimize hemodynamic and nutritional support, backup with early renal replacement intervention can prevent multiple organ failure and improve outcome.

Key words: Acute kidney Injury, Continuous renal replacement therapy, Sustained low efficiency daily dialysis

表1 急性肾损伤的诊断标准（KDIGO）

分期	血清肌酐值	尿量
1	上升为基础值的1.5~1.9倍或增加≥0.3 mg/dl（26.5 μmol/L）	<0.5 ml/（kg?h），连续6~12 h
2	上升为基础值的2.0~2.9倍	<0.5 ml/（kg?h），≥12 h
3	上升为基础值的3倍以上或增加到≥4 mg/dl（353.6 μmol/L），或开始肾脏替代治疗，或<18岁，肾小球滤过率（eGFR）<35 ml/（min?1.73 m²）	>0.3 ml/（kg?h），≥24 h或无尿>12 h

表1 急性肾损伤的诊断标准（KDIGO）

分期	血清肌酐值	尿量
1	上升为基础值的1.5~1.9倍或增加≥0.3 mg/dl（26.5 μmol/L）	<0.5 ml/（kg?h），连续6~12 h
2	上升为基础值的2.0~2.9倍	<0.5 ml/（kg?h），≥12 h
3	上升为基础值的3倍以上或增加到≥4 mg/dl（353.6 μmol/L），或开始肾脏替代治疗，或<18岁，肾小球滤过率（eGFR）<35 ml/（min?1.73 m²）	>0.3 ml/（kg?h），≥24 h或无尿>12 h

表2 急性肾损伤患者的蛋白质补充建议[g/（kg?d）]

指南	无肾脏替代治疗	间歇性肾脏替代治疗	连续性肾脏替代治疗
KDIGO^[3]	0.8~1.0	1.0~1.5	1.7
SCCM^[34]	1.2~2.0	~2.5	2.0~2.5

表2 急性肾损伤患者的蛋白质补充建议[g/（kg?d）]

指南	无肾脏替代治疗	间歇性肾脏替代治疗	连续性肾脏替代治疗
KDIGO^[3]	0.8~1.0	1.0~1.5	1.7
SCCM^[34]	1.2~2.0	~2.5	2.0~2.5

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