脓毒症急性肾损伤患者早期肾功能恢复的影响因素分析研究

目的：旨在分析脓毒症诱导的急性肾损伤（SA-AKI）患者肾功能早期恢复的影响因素。方法：回顾性分析2021年1月至2022年12月在复旦大学附属中山医院重症医学科治疗的86例同时符合脓毒症3.0诊断标准和AKI诊断标准的SA-AKI患者。根据其是否在7天内恢复肾功能将其分为恢复组（37例）和未恢复组（49例）。对两组患者的临床资料和实验室检查进行比较,采用单因素和多因素分析筛选变量,确定影响SA-AKI患者肾功能恢复的危险因素,使用ROC曲线评估各因素对SA-AKI早期肾功能恢复的预测价值。结果：SA-AKI的恢复率为43.02%（37/86）。与早期恢复组相比,未恢复组患者肾脏替代治疗率、住院死亡率和28天死亡率均更高（P<0.001）。年龄（P=0.047）、APACHE II评分（P=0.034）、尿量（P=0.025）、尿NGAL（P=0.038）、去甲肾上腺素剂量（P=0.035）是影响SA-AKI患者肾功能恢复的独立危险因素,用以上5个指标拟合出最终模型logit(P)=-4.091+0.001*尿NGAL-0.001*尿量+0.040*年龄+0.073*APACHEII评分+1.906*去甲肾上腺素剂量。该模型预测SA-AKI恢复的AUC为0.823,敏感度为73.5%,特异度为81.1%。结论：SA-AKI患者早期肾功能未恢复与预后不良相关。年龄、APACHE II评分、尿量、尿NGAL、去甲肾上腺素剂量为影响SA-AKI患者肾功能早期恢复的独立危险因素,联合指标的综合判断对SA-AKI患者早期肾损伤恢复具有预测价值。     

脓毒症急性肾损伤:一种微循环疾病

脓毒症急性肾损伤(acute kidney injury,AKI)时肾脏大循环和微循环呈现分离现象,肾脏血流正常甚至增加,而肾脏微循环缺血缺氧,表现为肾脏内血流分流,微循环灌注呈现异质现象,及微循环血流淤滞和梗阻,说明脓毒症AKI是一种微循环疾病,以微循环灌注为目标导向的治疗可能是今后的方向。     

脓毒症诱导急性肾损伤的研究进展

脓毒症是一种发病急、病情进展迅速、病死率高的危重疾病,急性肾损伤(AKI)被认为是预测脓毒症患者死亡的独立危险因素,但脓毒症诱导AKI的机制并不十分清楚.另外,RIFLE 标准中的血清肌酐增加和尿量减少已经使我们能够在相对早的阶段诊断AKI,中性粒细胞明胶酶相关载脂蛋白(NGAL)作为肾损伤的一种早期标志物,在诊断及早期治疗干预中可能发挥潜在的作用.本文在此对脓毒症诱导的AKI发病机制、早期诊断及生物学标志物的研究进展做一探讨.     

脓毒症急性肾损伤时血管活性药物的选择

急性肾损伤（acute kidney injury, AKI）与脓毒症关系密切且与较高的住院死亡率相关。脓毒症相关AKI发生的影响因素包括血流动力学改变、炎症和对肾小管上皮的直接损伤。在这篇文章中,我们从脓毒症相关AKI的流行病学和病理生理机制入手,重点讨论脓毒症相关肾脏血流动力学改变,并详细阐述了包括去甲肾上腺素、肾上腺素、加压素、多巴胺和苯肾上腺素等血管活性药物选择的相关问题,期待对相关领域的年轻医生有所帮助。     

脓毒症急性肾损伤的血液净化治疗

脓毒症急性肾损伤是危重症患者常见并发症,发病率和死亡率均较高。传统血液净化疗法如高容量血液滤过、多黏菌素B血液吸附、配对血浆滤过吸附、高截留量血液滤过等在脓毒症治疗上虽已取得部分临床疗效,但血液净化治疗脓毒症的机制、时机、剂量、频率等问题尚不明了。本课题组研发的生物反应器和粒细胞吸附等新型血液净化技术对脓毒症的治疗作用在动物实验中已得到初步证实。尽管处于初步研究阶段,但新型血液净化技术为脓毒症的血液净化治疗提供了新思路。     

脓毒症诱导急性肾损伤的防治进展

脓毒症诱导急性肾损伤是危重症患者常见的并发症之一,严重影响患者的预后和生命。对该并发症的早期防治和早期诊断处理可以改善患者的预后。本文对脓毒症诱导急性肾损伤的诊断和治疗进行回顾,以期改善这些患者的预后。     

细胞周期阻滞与脓毒症诱导的急性肾损伤研究进展

脓毒症是ICU中病死率较高的一类疾病,其可以导致多器官功能障碍综合征（MODS）,其中,脓毒症诱导的急性肾损伤（SAKI）发病率较高且与不良预后有关。目前对SAKI的发病机制缺乏全面的认识,这已成为其早期诊断和治疗的重要障碍。越来越多的研究证实,细胞周期阻滞作为一种肾脏的早期保护机制,是SAKI病理生理进程中的一项重要环节,可避免受损DNA的复制。本文总结细胞阻滞在SAKI中的作用机制,以及细胞周期阻滞的生物标志物,以期说明细胞周期阻滞可作为潜在治疗靶点,在早期预防或改善AKI预后中发挥作用。     

早期连续性血液净化治疗重度脓毒症合并急性肾损伤对肾功能、微循环及免疫状态的影响

目的本研究旨在探究早期行连续性血液净化治疗重度脓毒症合并急性肾损伤对肾功能、微循环及免疫状态的影响。方法收集2015年3月至2017年8月湖北省黄石市第二医院肾内科收治的54例重度脓毒症合并急性肾损伤患者,均给予早期器官功能支持治疗与连续性血液净化治疗,根据连续性血液净化治疗的时机不同将患者分为两组,其中早期组患者(n=3 0)接受连续性血液净化治疗的时间为发病12～24h,而对照组患者(n=24)接受连续性血液净化治疗的时间为发病24～48h。对比分析两组患者治疗前后的肾功能、微循环及免疫状态的变化情况。结果治疗后,两组患者的血浆内皮素(ET)、血清尿素氮(BUN)与肌酐(Scr)水平均较治疗前明显降低,且早期组患者明显低于对照组(P<0. 05);治疗后,早期组患者的总血管密度(TVD)较对照组患者更低,灌注血管密度(PVD)、灌注血管比例(PPV)、微血管流动指数(MFI)较对照组患者更高(P<0.05);治疗后两组患者的CD3^+百分比、CD4^+百分比、CD4^+/CD8^+的比值均较治疗前明显升高(P<0.05),且早期组明显高于对照组(P<0. 05)。结论早期行连续性血液净化治疗能够明显改善重度脓毒症合并急性肾损伤患者的肾功能和微循环状态,并升高CD3^+、CD4^+的百分比与CD4^+/CD8^+的比值,增强患者的免疫功能。     

脓毒症液体过负荷与急性肾损伤

脓毒症在重症监护病房(ICU)较为常见,早期充足的液体复苏是脓毒症和脓毒性休克血流动力学支持的核心,有助于纠正早期低血容量和最大限度地减少组织低灌注,特别是在血流动力学不稳定的患者中.虽然脓毒性休克患者早期静脉补液至少给予30?mL/kg这一观点还缺乏证据支持,但多数观察性研究将此作为早期容量复苏的常规治疗剂量.在容量...     

Renal blood flow and function during recovery from experimental septic acute kidney injury

Objective To measure renal blood flow (RBF) and renal function during recovery from experimental septic acute kidney injury (AKI). Design Controlled experimental study. Subjects Nine merino ewes. Setting University physiology laboratory. Intervention We recorded systemic and renal hemodynamics during a 96-h observation period (control) via implanted transit-time flow probes. We then compared this period with 96 h of septic AKI (48 h of Escherichia coli infusion) and subsequent recovery (48 h of observation after stopping E. coli). Measurements and results Compared with the control period, E. coli infusion induced hyperdynamic sepsis (increased cardiac output and decreased blood pressure) and septic AKI (serum creatinine 65.4 ± 8.7 vs. 139.9 ± 33.0 μmol/l; creatinine clearance 73.8 ± 12.2 vs. 40.2 ± 17.2 ml/min; p < 0.05) with a mortality of 22%. RBF increased (278.8 ± 33.9 vs. 547.9 ± 124.8 ml/min; p < 0.05) as did renal vascular conductance (RVC). During recovery, we observed a decrease in RVC and RBF with all values returning to control levels. Indices of tubular function [fractional excretion of sodium (FENa) and urea (FEUn) and urinary sodium concentration (UNa)], which had been affected by sepsis, returned to control values after 18 h of recovery, as did serum creatinine. Conclusions Infusion of E. coli induced a hyperdynamic circulatory state with hyperemic AKI. Recovery was associated with relative renal vasoconstriction and reduction in RBF and RVC back to control levels. Indices of tubular function normalized more rapidly than changes in RBF. This article is discussed in the editorial available at: .     

高截留滤器-连续性肾脏替代治疗在脓毒血症合并急性肾损伤中的应用进展CSCD

随着连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)技术和透析膜技术的进步并行,针对脓毒血症合并急性肾损伤的治疗手段逐渐丰富,其中高截留滤器在清除传统滤器不能有效覆盖的炎症因子上更有前景的获益,其在临床实践中有望更有选择性的去除大分子量的炎症介质,从而在抗感染治疗以外通过血液净化的方式进行全身炎症状态的有效干预。本综述特别关注高截留滤器的临床应用,包括已发表的该滤器相关研究中对炎症因子清除和对预后改善情况,概括了目前该滤器已发表研究的差异性和潜在应用方向。     

液体过负荷对脓毒症相关性AKI接受CRRT患者主要肾脏不良事件的影响

目的探讨液体过负荷（FO）对脓毒症相关性急性肾损伤（septic AKI）接受持续性肾替代治疗（CRRT）患者主要肾脏不良事件（MAKE）的影响。 方法对首都医科大学附属北京友谊医院重症医学科2015年1月至2019年6月收治的septic AKI接受CRRT的223例患者的临床资料进行回顾性分析,根据患者FO分为2组（FO＞5%和FO≤5%）,收集CRRT启动时患者的人口学特征,肌酐基线值,临床基本资料,合并症,实验室数据,ICU到CRRT时间,CRRT启动前24 h内尿量以及疾病严重程度评估,入院到CRRT启动时累计液体平衡。应用logistic回归分析观察FO是否是此类患者发生MAKE的独立危险因素。 结果223例接受CRRT的脓毒性AKI患者的MAKE发生率为72.1%;FO＞5%的患者28 d MAKE发生率明显高于FO≤5%的患者,差异有统计学意义（88.3% vs 60.2%,P＜0.001）。调整混杂因素的二元logistic回归显示FO＞5%的患者与发生MAKE风险独立相关（OR=4.680,95%CI：1.990~11.006,P＜0.001）。 结论在接受CRRT的septic AKI危重患者中,FO＞5%与MAKE风险增加独立相关。     

Urinary biomarkers in septic acute kidney injury

Objective To appraise the literature on the value of urinary biomarkers in septic acute kidney injury (AKI). Design Systematic review. Setting Academic medical centre. Patients and participants Human studies of urinary biomarkers. Interventions None. Measurements and results Fourteen articles fulfilled inclusion criteria. Most studies were small, single-centre, and included mixed medical/surgical adult populations. Few focused solely on septic AKI and all had notable limitations. Retrieved articles included data on low-molecular-weight proteins (β₂-microglobulin, α₁-microglobulin, adenosine deaminase binding protein, retinol binding protein, cystatin C, renal tubular epithelial antigen-1), enzymes (N-acetyl-β-glucosaminidase, alanine-aminopeptidase, alkaline phosphatase; lactate dehydrogenase, α/π-glutathione-S-transferase, γ-glutamyl transpeptidase), cytokines [platelet activating factor (PAF), interleukin-18 (IL-18)] and other biomarkers [kidney injury molecule-1, Na/H exchanger isoform-3 (NHE3)]. Increased PAF, IL-18, and NHE3 were detected early in septic AKI and preceded overt kidney failure. Several additional biomarkers were evident early in AKI; however, their diagnostic value in sepsis remains unknown. In one study, IL-18 excretion was higher in septic than in non-septic AKI. IL-18 also predicted deterioration in kidney function, with increased values preceding clinically significant kidney failure by 24–48 h. Detection of cystatin C, α₁-microglobulin, and IL-18 predicted need for renal replacement therapy (RRT). Conclusions Few clinical studies of urinary biomarkers in AKI have included septic patients. However, there is promising evidence that selected biomarkers may aid in the early detection of AKI in sepsis and may have value for predicting subsequent deterioration in kidney function. Additional prospective studies are needed to accurately describe their diagnostic and prognostic value in septic AKI.     

高容量血液滤过对感染性休克所致急性肾损伤影响的实验研究

目的研究高容量血液滤过(High Volume Hemofiltration,HVHF)对感染性休克所致急性肾损伤(Acute Kidney Injury,AKI)的影响,并探讨其可能机制。方法 18只猪随机分为对照组、连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)组和HVHF组,静脉注射大肠杆菌脂多糖(lipopolysaccharide,LPS)诱导感染性休克模型。各组给予液体复苏及血管活性药物维持保证组织灌注,复苏成功后根据分组给予不同处理:对照组不予特殊处理,CRRT组和HVHF组分别行超滤率为25ml/(kg·h)和85ml/(kg·h)的血液滤过治疗。记录各组血流动力学指标、血管活性药物用量及维持时间,检测血浆中IL-6和IL-10浓度、肾组织NF-k B表达水平,并观察肾组织病理改变。结果各组在给入LPS后约40~60min成功复制出休克模型;各组血流动力学指标在30min、40min、50min及60min时间点与基础相比差异均有统计学意义(P0.05);HVHF组CO值在T6时下降较少,高于基础正常值,与其它两组相比具有统计学差异(P0.05);HVHF组的d Pmax在T4、T5、T6时较其它两组有明显升高(P0.05);HVHF组的补液量较其它两组明显减少(P0.01),CRRT组较对照组减少(P0.05);在T4、T5、T6时间点HVHF组去甲肾上腺素用量较前下降,与其它两组相比有明显统计学差异(P0.01);与CRRT组相比,HVHF组IL-6在T3-T6下降明显,IL-10在T2-T6下降明显,差异均有统计学意义(P0.05);HVHF组肾NF-k B的m RNA相对表达量明显低于其它两组(P0.01),CRRT组低于对照组(P0.05);与对照组及CRRT组相比,HVHF组肾脏病理评分明显降低(P0.01)。结论 HVHF能够减少血管活性药物的用量和液体复苏量,有效降低血浆IL-6、IL-10浓度及肾组织NF-k B的表达水平,改善肾组织病理改变,对感染性AKI具有一定的肾保护作用。     

A pulmonary source of infection in patients with sepsis-associated acute kidney injury leads to a worse outcome and poor recovery of kidney function

BACKGROUND:Hospital mortality rates are higher among patients with sepsis-associated acute kidney injury(SA-AKI)than among patients with sepsis.However,the pathogenesis underlying SA-AKI remains unclear.We hypothesized that the source of infection affects development of SA-AKI.We aim to explore the relationship between the anatomical source of infection and outcome in patients with SA-AKI.METHODS:Between January 2013 and January 2018,113 patients with SA-AKI admitted to our Emergency Center were identifi ed and divided into two groups:those with pulmonary infections and those with other sources of infection.For each patient,we collected data from admission until either discharge or death.We also recorded the clinical outcome after 90 days for the discharged patients.RESULTS:The most common source of infection was the lung(52/113 cases,46%),followed by gastrointestinal(GI)(25/113 cases,22.1%)and urinary(22/113,19.5%)sources.Our analysis showed that patients with SA-AKI had a significantly worse outcome(30/52 cases,P<0.001)and poorer kidney recovery(P=0.015)with pulmonary sources of infection than those infected by another source.Data also showed that patients not infected by a pulmonary source more likely experienced shock(28/61 cases,P=0.037).CONCLUSION:This study demonstrated that the source of infection infl uenced the outcome of SA-AKI patients in an independent manner.Lung injury may influence renal function in an asyet undetermined manner as the recovery of kidney function was poorer in SA-AKI patients with a pulmonary source of infection.     

ICU急性肾损伤的高危因素分析

目的：探讨ICU住院患者急性肾损伤的危险因素。方法：回顾性分析重症监护病房2008-03-2013-03住院治疗的840例患者临床资料,应用多因素回归分析方法探讨发生急性肾损伤的高危因素。结果：840例患者中284例发生AKI,发病率为33.8%。284例AKI患者死亡68例,死亡率23.9%。年龄、APACHEⅡ分值、脓毒症、糖尿病、使用肾毒性药物、基线血肌酐值、休克是AKI发生的危险因素。结论：AKI是ICU中常见并发症,死亡率高。年龄、APACHEⅡ分值、脓毒症、糖尿病、使用肾毒性药物、基线血肌酐值、休克是AKI发生的独立危险因素,应采取多种综合措施减少AKI发生。     

NGAL与急性有机磷农药中毒急性肾损伤相关性研究

目的 探讨血清明胶酶相关脂质运载蛋白(NGAL)检测在急性有机磷农药中毒(AOPP)所致急性肾损伤(AKI)诊断、病情判断中的临床价值.方法 根据临床症状、乙酰胆碱酯酶活力及浓度将105例AOPP患者分为轻度组(35例)、中度组(38例)、重度组(32例),以50例体检健康者作为对照组.分别检测对照组及不同中毒程度组入院时、入院后1、3、5 d血清NGAL、肌酐(Scr)水平,分析AOPP患者NGAL阳性率、诊断AKI灵敏度和特异度,及其与中毒程度、持续时间的相关性.结果 AOPP患者AKI发病率为86.7%;入院后1 d内NGAL阳性率高达76.2%,与中毒程度呈正相关(P<0.05).NGAL水平在入院后1 d达峰值,随后开始下降.结论 AOPP患者AKI发病率高;NGAL是诊断AOPP早期AKI的理想指标,特异度为100.0%,灵敏度也较高;NGAL浓度、阳性率与AOPP中毒程度呈正相关.     

感染性休克合并急性肾损伤患者行配对血浆滤过吸附治疗的护理

目的 探索并总结感染性休克合并急性肾损伤患者行配对血浆滤过吸附治疗的护理。方法 总结我院2020年至2022年10例行配对血浆滤过吸附治疗的感染性休克合并急性肾损伤的患者。结果 10例患者中死亡1例,2例治疗出院后需持续血液透析,7例肾功能正常后停止血液净化治疗,治愈出院。治疗过程中未发生过敏,低血压,凝血、出血、栓塞等不良反应。结论 配对血浆滤过吸附治疗对感染性休克合并急性肾损伤的治疗具有较好的疗效。但在行配对血浆滤过吸附治疗过程中应注意透析前对患者的评估,透析过程中合理的参数设定,对患者体征与内稳态的严谨监测与对患者全程的心理护理,因而要求护士有良好的体力,细致的洞察力与高度的责任心。