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[JAMA读者来信]: 与全身性感染相关的急性肾损伤
2019年05月18日 研究点评, 进展交流 暂无评论

Comment & Response May 14, 2019

Acute Kidney Injury Related to Sepsis

David S. Seres

JAMA. 2019;321(18):1827-1828. doi:10.1001/jama.2019.2040

To the Editor 致编辑

Drs Legrand and Kellum reviewed the interpretation of serum creatinine in a critically ill patient.1 However, they only included a glancing reference to muscle mass and did not discuss protein intake. Both factors affect the evaluation of renal function and may have been important factors in this patient.

Legrand和Kellum医生复习了一名危重病患者血清肌酐水平的解读。然而,他们仅仅简单提及了肌肉量,并未讨论蛋白质摄入。这两个因素均能够影响肾脏功能的评估,对于此例患者可能是非常重要的因素。

The examination of muscle mass has garnered a large amount of attention in the United States. Hospital reimbursement is tied to identifying and treating comorbid conditions, and new diagnostic criteria for malnutrition rely heavily on muscle mass loss.2 However, assessing muscle mass loss is an important prognostic measure and tool for interpreting renal function.

肌肉量检查在美国受到了极大重视。医院报销与发现和治疗合并疾病密切相关,有关营养不良新的诊断标准高度依赖肌肉量丢失。然而,评估肌肉量丢失也是很重要的预后评价措施,且可用于肾脏功能解读。

In their 73-year-old patient with esophageal cancer, the serum creatinine was 0.81 mg/dL (71.6 μmol/L). It is likely his muscle mass was low (at least a 75% prevalence in a series of patients with esophageal cancer3), and the normal creatinine would, in fact, deserve upward adjustment (or the estimate of glomerular filtration downward adjustment) in the manner the authors did in response to excess fluid. Unfortunately, there is no formula for doing so based on muscle mass. I have seen increases in creatinine from 0.2 mg/dL (17.7 μmol/L) to 0.4 mg/dL (35 μmol/L) represent acute renal failure, necessitating hemodialysis in severely cachectic patients. Furthermore, the patient’s serum urea nitrogen on admission was at the low range of normal and increased within the normal range. If, as predicted, his intake, particularly of protein, had been and continued to be poor, his serum urea nitrogen would also deserve similar interpretation, suggesting worse renal function or the potential for more severely impaired renal perfusion.

在此例73岁食道癌患者,血清肌酐为0.81 mg/dL (71.6 μmol/L)。患者肌肉量很可能较小(至少占食道癌患者的75%),因此,患者肌酐水平正常事实上需要对肌酐水平进行上调(或对肾小球滤过率进行下调),正如作者对液体摄入过多进行校正。遗憾的是,尚没有根据肌肉量进行校正的公式。我曾见到过严重恶液质患者肌酐从0.2 mg/dL (17.7 μmol/L) 升高到 0.4 mg/dL (35 μmol/L),提示存在急性肾功能衰竭,需要进行血液透析治疗。而且,患者入院时血清尿素氮水平在正常值低限,随后在正常范围内逐渐升高。如果患者摄入,尤其是蛋白质摄入不足并保持如此,其血清尿素氮水平也需要进行相似解读,提示肾功能恶化或肾脏灌注出现严重障碍。

Identification of muscle mass and protein inanition may alter the interpretation of variations in renal function markers. Alarm for an increase in creatinine in patients noted to have cachexia or starvation should be sounded in a timely manner.

发现肌肉量及蛋白质不足可能改变对于肾功能标志物检查结果的解读。恶液质或饥饿患者肌酐水平升高应当进行及时处理。

Comment & Response May 14, 2019

Acute Kidney Injury Related to Sepsis

Mark A. Perazella

JAMA. 2019;321(18):1828. doi:10.1001/jama.2019.2044

To the Editor 致编辑

A JAMA Diagnostic Test Interpretation article addressed the test characteristics of serum creatinine in critically ill patients with sepsis.1 The authors presented a patient with pneumonia and septic shock who developed acute kidney injury (AKI) on day 3. They discussed serum creatinine as a marker of glomerular filtration rate (GFR), noting the deficiencies of the test in patients who have received significant volume resuscitation. They noted that the biomarkers of kidney injury do not directly measure GFR, but neither does serum creatinine.

JAMA诊断试验解读栏目的一篇文章谈及全身性感染危重患者血清肌酐检查的特征。作者介绍了一名肺炎合并感染性休克的患者在第3天发生了AKI。他们对血清肌酐作为GFR的标志物进行了讨论,指出这一检查用于接受容量复苏患者的缺点。他们还指出,肾损伤的生物标志物以及血清肌酐并不直接反映GFR。

I disagree with the authors that urinalysis is important for only some forms of AKI (such as glomerulonephritis) and lacks sensitivity and specificity. In fact, urinalysis, along with a spun urine sediment examination, provides key information about the presence and potential cause of AKI beyond the serum creatinine level.2,3 Studies have shown that urine sediment examination can differentiate common causes of AKI and predict worsening of AKI, need for dialysis, and death.3

我不同意作者的观点,即尿常规检查仅对于部分种类的AKI(如肾小球肾炎)具有重要意义,且敏感性和特异性不佳。事实上,与血清肌酐相比,尿常规检查联合尿沉渣检查能够为是否发生AKI及AKI的可能病因提供关键信息。研究表明,尿沉渣检查能够鉴别AKI的常见病因,并预测AKI恶化,透析需求及死亡。

In addition, the authors stated that vancomycin is nephrotoxic and should be avoided in patients with AKI. This is incorrect and potentially harmful to patients if this potentially lifesaving antibiotic is avoided in the setting of AKI because it is a nephrotoxin. The actual mechanism and incidence of vancomycin as a nephrotoxic cause of AKI is controversial. Vancomycin is associated with AKI with excessive levels, while some data suggest that long duration of therapy and combination with certain drugs may be nephrotoxic.4,5 However, vancomycin can and should be used in patients with AKI who are infected with a microorganism best treated with this agent. In fact, proper dosing and monitoring of levels to avoid excessive serum levels, which is the time when vancomycin may be nephrotoxic,4,5 is quite appropriate.

另外,作者提到,万古霉素具有肾毒性,AKI患者应避免使用。这种观点并不正确,而且对于AKI患者,仅仅因为可能挽救生命的抗生素具有肾毒性就避免使用,可能对患者是有害的。万古霉素肾毒性的确切机制及发生率存在争议。万古霉素血药浓度过高与AKI的发生具有相关性,部分数据提示,疗程过长以及与某些药物联合应用可能导致肾毒性的发生。然而,对于致病微生物敏感的AKI患者,能够并且应当使用万古霉素治疗。事实上,通过适当的剂量选择及药物浓度检测可以避免血药浓度过高,从而避免肾毒性发生。

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