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Nat Rev Nephrol:临床中术后急性肾损伤该如何管理?看这份全新共识怎么说!

2021-06-06 MedSci原创 MedSci原创

PO-AKI是一种异质性综合征,其临床过程是可变的。一个综合性的PO-AKI管理方法需要对整个围手术期的AKI风险、诊断、进展和结果进行一系列评估。

术后急性肾损伤(PO-AKI)是大手术的常见并发症,与短期手术并发症和长期不良结局密切相关,包括慢性肾脏疾病、血管事件和死亡的风险增加。PO-AKI的危险因素包括老年人以及慢性肾病和糖尿病等共病。

预防PO-AKI主要基于高基线风险的识别、监测和减少肾毒性损伤,而在治疗方面包括应用一系列干预措施以避免继发性肾损伤和减轻AKI的严重程度。于PO-AKI与长期不良结局密切相关,因此某种形式的KHA随访是必要的;在这个共识声明中,研究小组为非心脏手术后的AKI提供了分级建议,并强调未来研究的重点。

病理生理学和流行病学

与所有形式的AKI一样,PO-AKI代表一种临床综合征,而不是一种单一疾病,肾活检样本的有限组织学数据可用于确定特定的病理学。PO-AKI的常见机制包括缺血再灌注损伤、内源性或外源性肾毒素,物理原因则有阻塞、炎症因子、血管收缩和氧化应激等。因此,在手术环境中遇到的各种暴露与PO-AKI的形成有关。肾毒性药物在所有AKI发作中有20-30%与之相关,在外科手术中很常见。

了解PO-AKI的病理生理学和流行病学对于识别和开发新的预防性治疗方法至关重要。通过进行前瞻性研究,包括收集用于组织学和生物标志物检查的生物样本,以及对围手术期并发症的共同发病机制进行回顾性分析,可以提高这一认识。开发更好的PO-AKI风险预测工具有助于对患者进行风险分层,并设置预测风险阈值,以便在围手术期护理中进行调整。

术后AKI和AKD的预后

无论是何种促发机制,PO-AKI已被反复证明与高风险并发症相关,包括短期和长期死亡率、高医院成本和资源利用率。手术后入住重症监护病房至少24小时的患者的数据显示,即使肾功能完全恢复,经历过PO-AKI的患者在10年内的生存率也持续下降。相比之下,接受腹主动脉瘤破裂修补术(急性暴露风险极高)的患者的长期生存率在AKI患者和非AKI患者之间没有显著差异,这可能是由于在这种情况下即刻手术的巨大影响。

po-AKI和po-AKD的结局

对经历po-AKI或po-AKD患者的潜在监测方法

对于90天内出现持续性肾功能不全的患者,应正式评估其慢性肾病(CKD)的发展或进展情况。肾脏病参与随访监测的程度应随着AKI或AKD的持续时间和严重程度的增加而增加,与发生CKD的风险相称。较轻的AKI或AKD患者可以在初级保健或由基础专家进行监测,并根据CKD指南在需要时转介肾脏科治疗。

总之,PO-AKI是一种与短期手术并发症和长期不良后果密切相关的术后事件。在这一共识声明中,研究小组提供了一个关于AKI管理的概述。然而,PO-AKI是一种异质性综合征,其临床过程是可变的。一个综合性的PO-AKI管理方法需要对整个围手术期的AKI风险、诊断、进展和结果进行一系列评估。

参考文献:Prowle, J.R., Forni, L.G., Bell, M. et al. Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative. Nat Rev Nephrol (2021). https://doi.org/10.1038/s41581-021-00418-2

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    2022-01-04 liye789132251
  2. [GetPortalCommentsPageByObjectIdResponse(id=1885211, encodeId=9c7b1885211b9, content=<a href='/topic/show?id=3b2112532d8' target=_blank style='color:#2F92EE;'>#Nat#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12532, encryptionId=3b2112532d8, topicName=Nat)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=2e6f107, createdName=liye789132251, createdTime=Tue Jan 04 11:04:04 CST 2022, time=2022-01-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=974612, encodeId=90a69e461260, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1a272265480, createdName=12192b1am98暂无昵称, createdTime=Fri Jun 18 10:27:32 CST 2021, time=2021-06-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1398144, encodeId=34f21398144d4, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83eoNX3lUOlDKGBUEPNwZx0nibmdcFyeibnX4WMhUSCU2REpGRWtSmnT2CCs0dA5waxvJknYDxwtYnIcQ/132, createdBy=294e2500218, createdName=ms3046638856685384, createdTime=Tue Jun 08 14:04:04 CST 2021, time=2021-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=971427, encodeId=51259e1427b6, content=肾功很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b7a31928393, createdName=学医无涯, createdTime=Mon Jun 07 07:16:35 CST 2021, time=2021-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=971410, encodeId=76619e141074, content=学习了!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210606/3360b859ba944059aaffe8a1847ab57b/e91f325d086a40b2b9805211738111d1.jpg, createdBy=b3982392941, createdName=牟德武, createdTime=Sun Jun 06 23:19:37 CST 2021, time=2021-06-06, status=1, ipAttribution=)]
    2021-06-18 12192b1am98暂无昵称

    学习了

    0

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    2021-06-07 学医无涯

    肾功很重要

    0

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    2021-06-06 牟德武

    学习了!!

    0

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