急性肾脏病的概念沿革

doi:10.3877/cma.j.issn.1674-0785.2023.08.011

急性肾损伤（AKI）与慢性肾脏病（CKD）的概念，已被临床广泛认可并普遍应用于肾脏病领域的基础研究与临床实践。为定义肾脏病患者由AKI（7 d）过度至CKD（90 d）的阶段，ADQI工作组于2017年提出了急性肾脏病（AKD）的定义和分期。2021年，KDIGO发布专家共识更新了AKD的概念，将肾脏病根据患病持续时间是否超过3个月分为AKD与CKD，并将AKI划分为AKD的一个亚型，提出了AKD依据AKI和CKD的两种分期原则。本文结合AKD的概念革新以及最新研究结果，对AKD的新概念、流行病学、患者管理、临床预后等进行综述，供领域从业人员参考。

关键词: 急性肾脏病, 急性肾损伤, 慢性肾脏病, 分期, 评估

A consensus on the concept of acute kidney injury (AKI) and chronic kidney disease (CKD) has been reached and is widely used in basic research and clinical practice. In 2017, to define the stage of progression from AKI (7 d) to CKD (90 d) in patients with kidney diseases (KDs), the Acute Dialysis Quality Initiative (ADQI) working group proposed a consensus on the definition and staging of acute kidney disease (AKD). In 2021, Kidney Disease: Improving Global Outcomes (KDIGO) released an expert consensus to update the concept of AKD, dividing KDs into AKD and CKD based on whether the duration of the disease is more than 3 months, thus considering AKI a subtype of AKD, and proposing two staging principles of for AKD based on AKI or CKD. Referring to the latest elaboration of the concept of AKD by the KDIGO working group in 2021 and the latest studies on AKD, this article reviews the new concept, epidemiology, management strategies, and clinical prognosis of AKD to provide a reference for practitioners.

Key words: Acute kidney disease, Acute kidney injury, Chronic kidney disease, Staging, Evaluation

图1 图a为2017AQDI版AKD概念模型；图b为2021KDIGO版AKD概念模型

图2 AKD的分期与AKI、CKD分期之间的联系

表1 AKI、AKD、CKD、NKD的诊断标准⁹

因素

AKI

AKD

CKD

NKD

持续时间

< 7 d

≤ 90 d

> 90 d

功能损伤标准

7 d内SCr增加50%

或

2 d内SCr增加0.3 mg/dL（26.5 μmol/L）

或

6 h以上尿量＜0.5 ml/kg/h

AKI

或

GFR < 60 ml/min/1.73 m²

或

GFR降低35%以上

或

SCr升高50%以上

GFR < 60 ml/min/1.73 m²

GFR ≥ 60 ml/min/1.73 m²

结构损伤标准

未定义

有肾损伤指标（蛋白尿，血尿，影像学异常等）

有肾损伤指标（蛋白尿、血尿、影像学异常等）

无肾损伤指标

表1 AKI、AKD、CKD、NKD的诊断标准⁹

7 d内SCr增加50%

或

2 d内SCr增加0.3 mg/dL（26.5 μmol/L）

或

6 h以上尿量＜0.5 ml/kg/h

AKI

或

GFR < 60 ml/min/1.73 m²

或

GFR降低35%以上

或

SCr升高50%以上

GFR < 60 ml/min/1.73 m²

GFR ≥ 60 ml/min/1.73 m²

结构损伤标准

未定义

有肾损伤指标（蛋白尿，血尿，影像学异常等）

有肾损伤指标（蛋白尿、血尿、影像学异常等）

无肾损伤指标

表2 对AKD患者的临床评估项目建议

病史询问和初步检查

其他特殊检查和初步影像学诊断

血清学组织学和后续影像学诊断

1. 家族史，用药史（非处方药和毒品），既往史，职业暴露情况，近期旅居史，传染病史

2. 全面的查体，包括血压（卧立位）和血液容量状态，血常规，尿常规，血尿素氮、血肌酐，eGFR，电解质水平

尿蛋白定量和尿蛋白肌酐比

尿液培养

C反应蛋白

肝功能、血脂

甲状旁腺激素

凝血状态

普通放射学检查和超声

相关血清免疫学

肾穿刺（光镜，电镜，免疫荧光）

MRI

PET

核医学检查

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The last piece of picture puzzle: conceptual evolution of acute kidney disease

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The last piece of picture puzzle: conceptual evolution of acute kidney disease