Comment & Response May 14, 2019<\/p>\n\n\n\n
To the Editor<\/strong> \u81f4\u7f16\u8f91<\/p>\n\n\n\n Drs Legrand and Kellum reviewed the interpretation of serum creatinine in a critically ill patient.1<\/a><\/sup> 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.<\/p>\n\n\n\n Legrand\u548cKellum\u533b\u751f\u590d\u4e60\u4e86\u4e00\u540d\u5371\u91cd\u75c5\u60a3\u8005\u8840\u6e05\u808c\u9150\u6c34\u5e73\u7684\u89e3\u8bfb\u3002\u7136\u800c\uff0c\u4ed6\u4eec\u4ec5\u4ec5\u7b80\u5355\u63d0\u53ca\u4e86\u808c\u8089\u91cf\uff0c\u5e76\u672a\u8ba8\u8bba\u86cb\u767d\u8d28\u6444\u5165\u3002\u8fd9\u4e24\u4e2a\u56e0\u7d20\u5747\u80fd\u591f\u5f71\u54cd\u80be\u810f\u529f\u80fd\u7684\u8bc4\u4f30\uff0c\u5bf9\u4e8e\u6b64\u4f8b\u60a3\u8005\u53ef\u80fd\u662f\u975e\u5e38\u91cd\u8981\u7684\u56e0\u7d20\u3002<\/p>\n\n\n\n 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<\/a><\/sup> However, assessing muscle mass loss is an important prognostic measure and tool for interpreting renal function.<\/p>\n\n\n\n \u808c\u8089\u91cf\u68c0\u67e5\u5728\u7f8e\u56fd\u53d7\u5230\u4e86\u6781\u5927\u91cd\u89c6\u3002\u533b\u9662\u62a5\u9500\u4e0e\u53d1\u73b0\u548c\u6cbb\u7597\u5408\u5e76\u75be\u75c5\u5bc6\u5207\u76f8\u5173\uff0c\u6709\u5173\u8425\u517b\u4e0d\u826f\u65b0\u7684\u8bca\u65ad\u6807\u51c6\u9ad8\u5ea6\u4f9d\u8d56\u808c\u8089\u91cf\u4e22\u5931\u3002\u7136\u800c\uff0c\u8bc4\u4f30\u808c\u8089\u91cf\u4e22\u5931\u4e5f\u662f\u5f88\u91cd\u8981\u7684\u9884\u540e\u8bc4\u4ef7\u63aa\u65bd\uff0c\u4e14\u53ef\u7528\u4e8e\u80be\u810f\u529f\u80fd\u89e3\u8bfb\u3002<\/p>\n\n\n\n In their 73-year-old patient with esophageal cancer, the serum creatinine was 0.81 mg\/dL (71.6 \u03bcmol\/L). It is likely his muscle mass was low (at least a 75% prevalence in a series of patients with esophageal cancer3<\/a><\/sup>), 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 \u03bcmol\/L) to 0.4 mg\/dL (35 \u03bcmol\/L) represent acute renal failure, necessitating hemodialysis in severely cachectic patients. Furthermore, the patient\u2019s 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.<\/p>\n\n\n\n \u5728\u6b64\u4f8b73\u5c81\u98df\u9053\u764c\u60a3\u8005\uff0c\u8840\u6e05\u808c\u9150\u4e3a0.81 mg\/dL (71.6 \u03bcmol\/L)\u3002\u60a3\u8005\u808c\u8089\u91cf\u5f88\u53ef\u80fd\u8f83\u5c0f\uff08\u81f3\u5c11\u5360\u98df\u9053\u764c\u60a3\u8005\u768475%\uff09\uff0c\u56e0\u6b64\uff0c\u60a3\u8005\u808c\u9150\u6c34\u5e73\u6b63\u5e38\u4e8b\u5b9e\u4e0a\u9700\u8981\u5bf9\u808c\u9150\u6c34\u5e73\u8fdb\u884c\u4e0a\u8c03\uff08\u6216\u5bf9\u80be\u5c0f\u7403\u6ee4\u8fc7\u7387\u8fdb\u884c\u4e0b\u8c03\uff09\uff0c\u6b63\u5982\u4f5c\u8005\u5bf9\u6db2\u4f53\u6444\u5165\u8fc7\u591a\u8fdb\u884c\u6821\u6b63\u3002\u9057\u61be\u7684\u662f\uff0c\u5c1a\u6ca1\u6709\u6839\u636e\u808c\u8089\u91cf\u8fdb\u884c\u6821\u6b63\u7684\u516c\u5f0f\u3002\u6211\u66fe\u89c1\u5230\u8fc7\u4e25\u91cd\u6076\u6db2\u8d28\u60a3\u8005\u808c\u9150\u4ece0.2 mg\/dL (17.7 \u03bcmol\/L) \u5347\u9ad8\u5230 0.4 mg\/dL (35 \u03bcmol\/L)\uff0c\u63d0\u793a\u5b58\u5728\u6025\u6027\u80be\u529f\u80fd\u8870\u7aed\uff0c\u9700\u8981\u8fdb\u884c\u8840\u6db2\u900f\u6790\u6cbb\u7597\u3002\u800c\u4e14\uff0c\u60a3\u8005\u5165\u9662\u65f6\u8840\u6e05\u5c3f\u7d20\u6c2e\u6c34\u5e73\u5728\u6b63\u5e38\u503c\u4f4e\u9650\uff0c\u968f\u540e\u5728\u6b63\u5e38\u8303\u56f4\u5185\u9010\u6e10\u5347\u9ad8\u3002\u5982\u679c\u60a3\u8005\u6444\u5165\uff0c\u5c24\u5176\u662f\u86cb\u767d\u8d28\u6444\u5165\u4e0d\u8db3\u5e76\u4fdd\u6301\u5982\u6b64\uff0c\u5176\u8840\u6e05\u5c3f\u7d20\u6c2e\u6c34\u5e73\u4e5f\u9700\u8981\u8fdb\u884c\u76f8\u4f3c\u89e3\u8bfb\uff0c\u63d0\u793a\u80be\u529f\u80fd\u6076\u5316\u6216\u80be\u810f\u704c\u6ce8\u51fa\u73b0\u4e25\u91cd\u969c\u788d\u3002<\/p>\n\n\n\n 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.<\/p>\n\n\n\n \u53d1\u73b0\u808c\u8089\u91cf\u53ca\u86cb\u767d\u8d28\u4e0d\u8db3\u53ef\u80fd\u6539\u53d8\u5bf9\u4e8e\u80be\u529f\u80fd\u6807\u5fd7\u7269\u68c0\u67e5\u7ed3\u679c\u7684\u89e3\u8bfb\u3002\u6076\u6db2\u8d28\u6216\u9965\u997f\u60a3\u8005\u808c\u9150\u6c34\u5e73\u5347\u9ad8\u5e94\u5f53\u8fdb\u884c\u53ca\u65f6\u5904\u7406\u3002<\/p>\n\n\n\n Comment & Response May 14, 2019<\/p>\n\n\n\n To the Editor<\/strong>\u00a0\u81f4\u7f16\u8f91<\/p>\n\n\n\n A JAMA Diagnostic Test Interpretation article addressed the test characteristics of serum creatinine in critically ill patients with sepsis.1<\/a><\/sup>\u00a0The 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.<\/p>\n\n\n\n JAMA\u8bca\u65ad\u8bd5\u9a8c\u89e3\u8bfb\u680f\u76ee\u7684\u4e00\u7bc7\u6587\u7ae0\u8c08\u53ca\u5168\u8eab\u6027\u611f\u67d3\u5371\u91cd\u60a3\u8005\u8840\u6e05\u808c\u9150\u68c0\u67e5\u7684\u7279\u5f81\u3002\u4f5c\u8005\u4ecb\u7ecd\u4e86\u4e00\u540d\u80ba\u708e\u5408\u5e76\u611f\u67d3\u6027\u4f11\u514b\u7684\u60a3\u8005\u5728\u7b2c3\u5929\u53d1\u751f\u4e86AKI\u3002\u4ed6\u4eec\u5bf9\u8840\u6e05\u808c\u9150\u4f5c\u4e3aGFR\u7684\u6807\u5fd7\u7269\u8fdb\u884c\u4e86\u8ba8\u8bba\uff0c\u6307\u51fa\u8fd9\u4e00\u68c0\u67e5\u7528\u4e8e\u63a5\u53d7\u5bb9\u91cf\u590d\u82cf\u60a3\u8005\u7684\u7f3a\u70b9\u3002\u4ed6\u4eec\u8fd8\u6307\u51fa\uff0c\u80be\u635f\u4f24\u7684\u751f\u7269\u6807\u5fd7\u7269\u4ee5\u53ca\u8840\u6e05\u808c\u9150\u5e76\u4e0d\u76f4\u63a5\u53cd\u6620GFR\u3002<\/p>\n\n\n\n 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<\/a><\/sup>,3<\/a><\/sup>\u00a0Studies have shown that urine sediment examination can differentiate common causes of AKI and predict worsening of AKI, need for dialysis, and death.3<\/a><\/sup><\/p>\n\n\n\n \u6211\u4e0d\u540c\u610f\u4f5c\u8005\u7684\u89c2\u70b9\uff0c\u5373\u5c3f\u5e38\u89c4\u68c0\u67e5\u4ec5\u5bf9\u4e8e\u90e8\u5206\u79cd\u7c7b\u7684AKI\uff08\u5982\u80be\u5c0f\u7403\u80be\u708e\uff09\u5177\u6709\u91cd\u8981\u610f\u4e49\uff0c\u4e14\u654f\u611f\u6027\u548c\u7279\u5f02\u6027\u4e0d\u4f73\u3002\u4e8b\u5b9e\u4e0a\uff0c\u4e0e\u8840\u6e05\u808c\u9150\u76f8\u6bd4\uff0c\u5c3f\u5e38\u89c4\u68c0\u67e5\u8054\u5408\u5c3f\u6c89\u6e23\u68c0\u67e5\u80fd\u591f\u4e3a\u662f\u5426\u53d1\u751fAKI\u53caAKI\u7684\u53ef\u80fd\u75c5\u56e0\u63d0\u4f9b\u5173\u952e\u4fe1\u606f\u3002\u7814\u7a76\u8868\u660e\uff0c\u5c3f\u6c89\u6e23\u68c0\u67e5\u80fd\u591f\u9274\u522bAKI\u7684\u5e38\u89c1\u75c5\u56e0\uff0c\u5e76\u9884\u6d4bAKI\u6076\u5316\uff0c\u900f\u6790\u9700\u6c42\u53ca\u6b7b\u4ea1\u3002<\/p>\n\n\n\n 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<\/a><\/sup>,5<\/a><\/sup>\u00a0However, 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<\/a><\/sup>,5<\/a><\/sup>\u00a0is quite appropriate.<\/p>\n\n\n\n \u53e6\u5916\uff0c\u4f5c\u8005\u63d0\u5230\uff0c\u4e07\u53e4\u9709\u7d20\u5177\u6709\u80be\u6bd2\u6027\uff0cAKI\u60a3\u8005\u5e94\u907f\u514d\u4f7f\u7528\u3002\u8fd9\u79cd\u89c2\u70b9\u5e76\u4e0d\u6b63\u786e\uff0c\u800c\u4e14\u5bf9\u4e8eAKI\u60a3\u8005\uff0c\u4ec5\u4ec5\u56e0\u4e3a\u53ef\u80fd\u633d\u6551\u751f\u547d\u7684\u6297\u751f\u7d20\u5177\u6709\u80be\u6bd2\u6027\u5c31\u907f\u514d\u4f7f\u7528\uff0c\u53ef\u80fd\u5bf9\u60a3\u8005\u662f\u6709\u5bb3\u7684\u3002\u4e07\u53e4\u9709\u7d20\u80be\u6bd2\u6027\u7684\u786e\u5207\u673a\u5236\u53ca\u53d1\u751f\u7387\u5b58\u5728\u4e89\u8bae\u3002\u4e07\u53e4\u9709\u7d20\u8840\u836f\u6d53\u5ea6\u8fc7\u9ad8\u4e0eAKI\u7684\u53d1\u751f\u5177\u6709\u76f8\u5173\u6027\uff0c\u90e8\u5206\u6570\u636e\u63d0\u793a\uff0c\u7597\u7a0b\u8fc7\u957f\u4ee5\u53ca\u4e0e\u67d0\u4e9b\u836f\u7269\u8054\u5408\u5e94\u7528\u53ef\u80fd\u5bfc\u81f4\u80be\u6bd2\u6027\u7684\u53d1\u751f\u3002\u7136\u800c\uff0c\u5bf9\u4e8e\u81f4\u75c5\u5fae\u751f\u7269\u654f\u611f\u7684AKI\u60a3\u8005\uff0c\u80fd\u591f\u5e76\u4e14\u5e94\u5f53\u4f7f\u7528\u4e07\u53e4\u9709\u7d20\u6cbb\u7597\u3002\u4e8b\u5b9e\u4e0a\uff0c\u901a\u8fc7\u9002\u5f53\u7684\u5242\u91cf\u9009\u62e9\u53ca\u836f\u7269\u6d53\u5ea6\u68c0\u6d4b\u53ef\u4ee5\u907f\u514d\u8840\u836f\u6d53\u5ea6\u8fc7\u9ad8\uff0c\u4ece\u800c\u907f\u514d\u80be\u6bd2\u6027\u53d1\u751f\u3002<\/p>\n","protected":false},"excerpt":{"rendered":" Comment & Response May 14, 2019 Acut […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17183"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=17183"}],"version-history":[{"count":3,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17183\/revisions"}],"predecessor-version":[{"id":17191,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17183\/revisions\/17191"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=17183"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=17183"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=17183"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Acute Kidney Injury Related to Sepsis<\/h1>\n\n\n\n
Mark A.\u00a0Perazella<\/h3>\n\n\n\n
JAMA.\u00a0<\/em>2019;321(18):1828. doi:10.1001\/jama.2019.2044<\/h3>\n\n\n\n