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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.


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.


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.


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.


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


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.



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