{"id":17186,"date":"2019-05-27T05:06:51","date_gmt":"2019-05-26T21:06:51","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=17186"},"modified":"2019-06-02T06:41:35","modified_gmt":"2019-06-01T22:41:35","slug":"jama%e4%bd%9c%e8%80%85%e5%9b%9e%e5%a4%8d%ef%bc%9a%e5%85%a8%e8%ba%ab%e6%80%a7%e6%84%9f%e6%9f%93%e7%9b%b8%e5%85%b3%e6%80%a5%e6%80%a7%e8%82%be%e6%8d%9f%e4%bc%a4-%e5%9b%9e%e5%a4%8d","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=17186","title":{"rendered":"[JAMA\u4f5c\u8005\u56de\u590d]\uff1a\u5168\u8eab\u6027\u611f\u67d3\u76f8\u5173\u6025\u6027\u80be\u635f\u4f24 \u2014 \u56de\u590d"},"content":{"rendered":"\n

Comment & Response May 14, 2019<\/p>\n\n\n\n

Acute Kidney Injury Related to Sepsis\u2014Reply<\/h1>\n\n\n\n

Matthieu Legrand, John A. Kellum<\/h3>\n\n\n\n

JAMA. <\/em>2019;321(18):1828-1829. doi:10.1001\/jama.2019.2072<\/h3>\n\n\n\n

In Reply<\/strong> \u56de\u7b54<\/p>\n\n\n\n

Dr Seres comments on the effect of low muscle mass on serum creatinine level. We agree that muscle mass and cachexia can decrease sensitivity of serum creatinine to detect a drop in GFR and AKI. Recently, Yoo and colleagues1<\/a><\/sup> reported overestimation of GFR in patients with cirrhosis and with low muscle mass detected by abdominal computed tomography.2<\/a><\/sup> This point was addressed in our article1<\/a><\/sup> when considering the overestimation of GFR using serum creatinine at discharge from the intensive care unit due to muscle mass loss during the stay. Estimation of GFR based on creatinine clearance may be more accurate in this setting. Short-term (2-4 hours) urine collection may overcome some of the limits of creatinine clearance measurements to detect acute changes in GFR.3<\/a><\/sup><\/p>\n\n\n\n

Seres\u533b\u751f\u5c31\u6709\u5173\u4f4e\u808c\u8089\u91cf\u5bf9\u4e8e\u8840\u6e05\u808c\u9150\u6c34\u5e73\u7684\u5f71\u54cd\u8fdb\u884c\u4e86\u8bc4\u8bba\u3002\u808c\u8089\u91cf\u4e0e\u6076\u6db2\u8d28\u80fd\u591f\u964d\u4f4e\u8840\u6e05\u808c\u9150\u53d1\u73b0GFR\u4e0b\u964d\u548cAKI\u7684\u654f\u611f\u6027\uff0c\u6211\u4eec\u5bf9\u6b64\u8868\u793a\u8d5e\u540c\u3002\u8fd1\u671f\uff0cYoo\u53ca\u5176\u540c\u4e8b\u62a5\u544a\uff0c\u5bf9\u4e8e\u809d\u786c\u5316\u60a3\u8005\u53ca\u8179\u90e8CT\u68c0\u67e5\u53d1\u73b0\u808c\u8089\u91cf\u4f4e\u7684\u60a3\u8005\uff0cGFR\u5f80\u5f80\u88ab\u9ad8\u4f30\u3002\u6211\u4eec\u7684\u6587\u7ae0\u4e2d\u4e5f\u8c08\u5230\u4e86\u8fd9\u4e00\u70b9\uff0c\u5373\u7531\u4e8e\u4f4fICU\u671f\u95f4\u808c\u8089\u91cf\u4e22\u5931\uff0c\u56e0\u6b64\u6839\u636e\u8f6c\u51faICU\u65f6\u7684\u8840\u6e05\u808c\u9150\u53ef\u80fd\u9ad8\u4f30GFR\u3002\u8fd9\u79cd\u60c5\u51b5\u4e0b\uff0c\u6839\u636e\u808c\u9150\u6e05\u9664\u7387\u4f30\u8ba1GFR\u53ef\u80fd\u66f4\u52a0\u51c6\u786e\u3002\u6536\u96c6\u77ed\u671f\uff082-4\u5c0f\u65f6\uff09\u5c3f\u6db2\u53ef\u80fd\u514b\u670d\u901a\u8fc7\u808c\u9150\u6e05\u9664\u7387\u53d1\u73b0GFR\u6025\u6027\u6539\u53d8\u7684\u67d0\u4e9b\u5c40\u9650\u6027\u3002<\/p>\n\n\n\n

Dr Perazella mentions the use of urine sediment as a biomarker of kidney disease. However, data on the use of urine sediment in septic AKI are scarce. In a 2-center prospective study, urine sediment was analyzed in 73 patients and showed a higher urine microscopy score (based on renal tubular epithelial cells and granular cast observation) in patients with septic vs nonseptic AKI.4<\/a><\/sup>\u00a0Urine microscopy was specific but poorly sensitive to detect worsening AKI (urine microscopy score \u22653 had a sensitivity of 0.67 [95% CI, 0.39-0.86] and specificity of 0.95 [95% CI, 0.84-0.99]). Urine sediment may help establish the cause of AKI and provide prognostic information but has poor sensitivity to detect AKI and worsening of AKI. Furthermore, it is not an indicator of GFR.<\/p>\n\n\n\n

Perazella\u533b\u751f\u63d0\u5230\uff0c\u5c3f\u6c89\u6e23\u53ef\u4ee5\u4f5c\u4e3a\u80be\u810f\u75be\u75c5\u7684\u751f\u7269\u6807\u5fd7\u7269\u3002\u7136\u800c\uff0c\u5168\u8eab\u6027\u611f\u67d3\u5f15\u8d77\u7684AKI\u4e2d\uff0c\u6709\u5173\u5c3f\u6c89\u6e23\u7684\u6570\u636e\u975e\u5e38\u5c11\u3002\u5728\u4e00\u98792\u4e2a\u4e2d\u5fc3\u53c2\u52a0\u7684\u524d\u77bb\u6027\u7814\u7a76\u4e2d\uff0c\u5171\u5bf973\u540d\u60a3\u8005\u7684\u5c3f\u6c89\u6e23\u8fdb\u884c\u4e86\u5206\u6790\u3002\u7ed3\u679c\u8868\u660e\uff0c\u4e0e\u975e\u5168\u8eab\u6027\u611f\u67d3AKI\u76f8\u6bd4\uff0c\u5168\u8eab\u6027\u611f\u67d3AKI\u60a3\u8005\u5c3f\u663e\u5fae\u955c\u8bc4\u5206\uff08\u57fa\u4e8e\u5c3f\u6db2\u4e2d\u5c0f\u7ba1\u4e0a\u76ae\u7ec6\u80de\u53ca\u9897\u7c92\u7ba1\u578b\uff09\u66f4\u9ad8\u3002\u5c3f\u663e\u5fae\u955c\u68c0\u7528\u4e8e\u53d1\u73b0AKI\u6076\u5316\u5177\u6709\u8f83\u597d\u7684\u7279\u5f02\u6027\uff0c\u4f46\u654f\u611f\u6027\u4e0d\u4f73\uff08\u5c3f\u663e\u5fae\u955c\u8bc4\u5206\u2265 3\u7684\u654f\u611f\u60270.67 [95% CI, 0.39-0.86]\uff0c\u7279\u5f02\u60270.95 [95% CI, 0.84-0.99]\uff09\u3002\u5c3f\u6c89\u6e23\u53ef\u80fd\u6709\u52a9\u4e8e\u660e\u786eAKI\u7684\u539f\u56e0\uff0c\u5e76\u63d0\u4f9b\u9884\u540e\u4fe1\u606f\uff0c\u4f46\u662f\u5bf9\u4e8e\u68c0\u6d4bAKI\u53caAKI\u6076\u5316\u7684\u654f\u611f\u6027\u8f83\u4f4e\u3002 \u800c\u4e14\uff0c\u5c3f\u6c89\u6e23\u5e76\u4e0d\u80fd\u53cd\u6620GFR\u3002<\/p>\n\n\n\n

Perazella also challenges the renal toxicity of vancomycin. While renal toxicity of vancomycin has been controversial, current evidence establishes the drug as a nephrotoxin.5<\/a><\/sup>\u00a0We agree that appropriate antibiotic treatment of sepsis is crucial and should not be delayed. However, safe and effective alternatives to vancomycin are often available to treat patients with proven or suspected infection with methicillin-resistant\u00a0Staphylococcus aureus<\/em>\u00a0(eg, linezolid in a patient with pneumonia such as in our case) with a decreased risk of renal toxicity. Limiting additional factors that contribute to kidney injury is expected to limit the duration of AKI and promote recovery.<\/p>\n\n\n\n

Perazella\u8fd8\u5bf9\u4e07\u53e4\u9709\u7d20\u7684\u80be\u6bd2\u6027\u63d0\u51fa\u4e86\u8d28\u7591\u3002\u5c3d\u7ba1\u4e07\u53e4\u9709\u7d20\u7684\u80be\u6bd2\u6027\u5b58\u5728\u4e89\u8bae\uff0c\u4f46\u73b0\u6709\u8bc1\u636e\u8868\u660e\uff0c\u8fd9\u79cd\u836f\u7269\u5177\u6709\u80be\u6bd2\u6027\u3002\u6211\u4eec\u540c\u610f\u9488\u5bf9\u5168\u8eab\u6027\u611f\u67d3\u7684\u6b63\u786e\u6297\u751f\u7d20\u6cbb\u7597\u975e\u5e38\u91cd\u8981\u4e14\u4e0d\u5e94\u5ef6\u8fdf\u3002\u7136\u800c\uff0c\u6211\u4eec\u53ef\u4ee5\u9009\u62e9\u5b89\u5168\u53ca\u6709\u6548\u7684\u6297\u751f\u7d20\u66ff\u4ee3\u4e07\u53e4\u9709\u7d20\uff0c\u6cbb\u7597\u786e\u8bca\u6216\u7591\u4f3c\u7684MRSA\u611f\u67d3\uff08\u5982\u6211\u4eec\u7684\u75c5\u4f8b\u4e3a\u80ba\u708e\u60a3\u8005\u63a5\u53d7\u5229\u5948\u5511\u80fa\u7684\u6cbb\u7597\uff09\uff0c\u4ece\u800c\u964d\u4f4e\u80be\u6bd2\u6027\u98ce\u9669\u3002\u9650\u5236\u9020\u6210\u80be\u635f\u4f24\u7684\u5176\u4ed6\u56e0\u7d20\u6709\u53ef\u80fd\u7f29\u77edAKI\u75c5\u7a0b\u5e76\u4fc3\u8fdb\u80be\u810f\u6062\u590d\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\/17186"}],"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=17186"}],"version-history":[{"count":2,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17186\/revisions"}],"predecessor-version":[{"id":17189,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17186\/revisions\/17189"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=17186"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=17186"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=17186"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}