急性肾脏病的概念与分期及流行病学

doi:10.3877/cma.j.issn.2095-3216.2017.06.002

急性肾损伤(AKI)和慢性肾脏病(CKD)是相互关联的临床综合征，均表现为肾脏受损和肾小球滤过率(GFR)下降。研究表明AKI后肾功能完全恢复的患者仍有可能存在肾脏结构的异常，从而增加CKD和终末期肾脏病(ESRD)的风险。然而，部分患者肾脏功能损伤和结构异常可能达不到目前AKI或CKD的诊断标准。因此，2012年KDIGO关于AKI临床实践指南提出了一个新的概念-急性肾脏病和功能障碍，包括了AKI和其他最新研究认识的不符合AKI或CKD诊断标准的肾脏疾病。这一概念的提出有助于增加对各种急慢性肾脏疾病的识别和交流，并提高肾脏病领域相关的医疗、科研和公共卫生水平。本文阐述了急性肾脏病(AKD)的概念和分期，同时介绍了AKD相关的流行病学现状以及未来研究方向，旨在帮助临床医师正确识别和评估各种急慢性肾脏疾病。

关键词: 急性肾脏病, 急性肾损伤, 慢性肾脏病, 概念, 分级, 流行病学

Acute kidney injury (AKI) and chronic kidney disease (CKD) are interconnected clinical syndromes, and both manifest kidney injury and a decrease in glomerular filtration rate (GFR). Studies have shown that patients with AKI may still have abnormalities in the renal structure after complete recovery of renal function, thereby increasing the risk of CKD and end-stage renal disease (ESRD). However, some patients with renal dysfunction and structural abnormalities may not reach the current diagnostic criteria of AKI or CKD. Therefore, in 2012, the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines for AKI put forward a new concept, acute kidney diseases and disorders, which includes AKI and other newly-identified kidney diseases that do not meet AKI or CKD diagnostic criteria. This new concept was proposed to help increase the identification and exchange of various acute and chronic kidney diseases, and to increase the medical, scientific, and public health levels of the kidney disease field. This article described the concept and staging of acute kidney disease (AKD), as well as the current epidemiological status of AKD and future research directions, aiming to help clinicians correctly identify and assess various acute and chronic kidney diseases.

Key words: Acute kidney diseases (AKD), Acute kidney injury (AKI), Chronic kidney disease (CKD), Definition, Stage, Epidemiology

表1 AKI、CKD和AKD的定义

?	功能标准	结构标准
AKI	血肌酐在7 d内升高50%，或者血肌酐在2 d内升高26.5 μmol/L (0.3 mg/dl)，或者少尿	无肾损害
CKD	GFR<60 ml/(min·1.73 m²)大于3个月	肾损害大于3个月
AKD	AKI，或者GFR<60 ml/(min·1.73 m²)小于3个月，或者GFR下降>35%或者血肌酐升高>50%不足3个月	肾损害小于3个月
NKD	3个月内GFR≥60 ml/(min·1.73 m²)，并且血肌酐稳定	无肾损害

表1 AKI、CKD和AKD的定义

?	功能标准	结构标准
AKI	血肌酐在7 d内升高50%，或者血肌酐在2 d内升高26.5 μmol/L (0.3 mg/dl)，或者少尿	无肾损害
CKD	GFR<60 ml/(min·1.73 m²)大于3个月	肾损害大于3个月
AKD	AKI，或者GFR<60 ml/(min·1.73 m²)小于3个月，或者GFR下降>35%或者血肌酐升高>50%不足3个月	肾损害小于3个月
NKD	3个月内GFR≥60 ml/(min·1.73 m²)，并且血肌酐稳定	无肾损害

表2 急性肾脏病的分期标准

分期	定义
0^a	A：不符合标准B或C
?	B：具有持续损伤、修复和(或)再生，肾小球或肾小管功能降低的表现
?	C：血肌酐是基线水平的1.5倍以下，但未恢复到基线水平
?	B/C：血肌酐小于基线水平的1.5倍，但未恢复到基线水平，具有持续损伤、修复和(或)再生表现
1	血肌酐水平是基线水平的1.5～1.9倍
2	血肌酐水平是基线水平的2.0～2.9倍
3	血肌酐水平是基线水平的3.0倍或血肌酐增至353.6 μmol/L^b或需要肾脏替代治疗

表2 急性肾脏病的分期标准

分期	定义
0^a	A：不符合标准B或C
?	B：具有持续损伤、修复和(或)再生，肾小球或肾小管功能降低的表现
?	C：血肌酐是基线水平的1.5倍以下，但未恢复到基线水平
?	B/C：血肌酐小于基线水平的1.5倍，但未恢复到基线水平，具有持续损伤、修复和(或)再生表现
1	血肌酐水平是基线水平的1.5～1.9倍
2	血肌酐水平是基线水平的2.0～2.9倍
3	血肌酐水平是基线水平的3.0倍或血肌酐增至353.6 μmol/L^b或需要肾脏替代治疗

1	Kidney Disease: Improving Global Outcomes AKI Work Group. KDIGO clinical practice guideline for acute kidney injury [J]. Kidney Int Suppl, 2012, 2(1): 1-138.
2	Bellomo R, Kellum JA, Ronco C. Acute kidney injury [J]. Lancet, 2010, 380(9843): 756-766.
3	Mehta RL, Burdmann EA, Cerdá J, et al. Recognition and management of acute kidney injury in the International Society of Nephrology: a multinational cross-sectional study [J]. Lancet, 2016, 387(10032): 2017-2025.
4	Greenberg JH, Coca S, Parikh CR. Long-term risk of chronic kidney disease and mortality in children after acute kidney injury: a systematic review [J]. BMC Nephrol, 2014, 15(1): 1-11.
5	Webster AC, Nagler EV, Morton RL. Chronic kidney disease [J]. Lancet, 2012, 379(9811): 165-180.
6	Goldstein SL, Jaber BL, Faubel S, et al. AKI transition of care: a potential opportunity to detect and prevent CKD [J]. Clin J Am Soc Nephrol, 2013, 8(3): 476-483.
7	Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: a systematic review [J]. Kidney Int, 2008, 73(5): 538-546.
8	Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy [J]. BMJ, 2012, 344: e3502.
9	Levey AS, Jong PED, Coresh J, et al. The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report [J]. Kidney Int, 2011, 80(1): 17-28.
10	Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group [J]. Crit Care, 2004, 8(4): R204-R212.
11	Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury [J]. Crit Care, 2007, 11(2): R31.
12	National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease evaluationm, classification, and stratification [J]. Am J Kidney Dis, 2002, 39(Suppl 1): 1-266.
13	Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease [J]. Kidney Int Suppl, 2013, 3(1): 1-150.
14	Barry R, James MT. Guidelines for classification of acute kidney diseases and disorders [J]. Nephron, 2015, 131(4): 221-226.
15	Chawla LS, Bellomo R, Bihorac A, et al. Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) Work Group [J]. Nat Rev Nephrol, 2017, 13(4): 241-257.
16	Chawla LS, Kimmel PL. Acute kidney injury and chronic kidney disease: an integrated clinical syndrome [J]. Kidney Int, 2012, 82(5): 516-524.
17	Chawla LS, Eggers PW, Star RA, et al. Acute kidney injury and chronic kidney disease as interconnected syndromes [J]. N Engl J Med, 2014, 371(1): 58-66.
18	Susantitaphong P, Cruz DN, Cerda J, et al. World incidence of AKI: a meta-analysis [J]. Clin J Am Soc Nephrol, 2013, 8(9): 1482-1493.
19	Fang Y, Ding X, Zhong Y, et al. Acute kidney injury in a Chinese hospitalized population [J]. Blood Purif, 2010, 30(2): 120-126.
20	Yang L, Xing G, Wang L, et al. Acute kidney injury in China: a cross-sectional survey [J]. Lancet, 2015, 386(10002): 1465-1471.
21	Xin X, Sheng N, Liu Z, et al. Epidemiology and clinical correlates of AKI in Chinese hospitalized adults[J]. Clin J Am Soc Nephrol, 2015, 10(9): 1510-1518.
22	Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis [J]. Kidney Int, 2012, 81(5): 442-448.
23	Chawla LS, Amdur RL, Amodeo S, et al. The severity of acute kidney injury predicts progression to chronic kidney disease [J]. Kidney Int, 2011, 79(12): 1361-1369.
24	Sawhney S, Marks A, Fluck N, et al. Intermediate and long-term outcomes of survivors of acute kidney injury episodes: a large population-based cohort study [J]. Am J Kidney Dis, 2016, 69(1): 18-28.
25	James MT, Ghali WA, Knudtson ML, et al. Associations between acute kidney injury and cardiovascular and renal outcomes after coronary angiography [J]. Circulation, 2011, 123(4): 409-416.
26	Amdur RL, Chawla LS, Amodeo S, et al. Outcomes following diagnosis of acute renal failure in US veterans: focus on acute tubular necrosis [J]. Kidney Int, 2009, 76(10): 1089-1097.
27	Stoumpos S, Mark PB, Mcquarrie EP, et al. Continued monitoring of acute kidney injury survivors might not be necessary in those regaining an estimated glomerular filtration rate >60 mL/min at 1 year [J]. Nephrol Dial Transplant, 2017, 32(1): 81-88.
28	Thakar CV, Christianson A, Himmelfarb J, et al. Acute kidney injury episodes and chronic kidney disease risk in diabetes mellitus [J]. Clin J Am Soc Nephrol, 2011, 6(11): 2567-2572.
29	Sawhney S, Mitchell M, Marks A, et al. Long-term prognosis after acute kidney injury (AKI): what is the role of baseline kidney function and recovery? [J]. BMJ Open, 2015, 5(1): e006497.
30	James MT, Hemmelgarn BR, Wiebe N, et al. Glomerular filtration rate, proteinuria, and the incidence and consequences of acute kidney injury: a cohort study [J]. Lancet, 2010, 376(9758): 2096-2103.
31	Heung M, Steffick DE, Zivin K, et al. Acute kidney injury recovery pattern and subsequent risk of CKD: an analysis of veterans health administration data [J]. Am J Kidney Dis, 2016, 67(5): 742-752.
32	Ali T, Khan I, Simpson W, et al. Incidence and outcomes in acute kidney injury: a comprehensive population-based study [J]. J Am Soc Nephrol, 2007, 18(4): 1292-1298.
33	Ishani A, Xue JL, Himmelfarb J, et al. Acute kidney injury increases risk of ESRD among elderly [J]. J Am Soc Nephrol, 2009, 20(1): 223-228.
34	Pannu N, James M, Hemmelgarn BR, et al. Modification of outcomes after acute kidney injury by the presence of CKD [J]. Am J Kidney Dis, 2011, 58(2): 206-213.
35	Odutayo A, Wong CX, Farkouh M, et al. AKI and long-term risk for cardiovascular events and mortality [J]. J Am Soc Nephrol, 2017, 28(1): 377-387.
36	Kaushal GP, Shah SV. Challenges and advances in the treatment of AKI [J]. J Am Soc Nephrol, 2014, 25(5): 877-883.
37	Lewington AJP, Cerdá J, Mehta RL. Raising awareness of acute kidney injury: a global perspective of a silent killer [J]. Kidney Int, 2013, 84(3): 457-467.
38	Levey AS, Becker C, Inker LA. Glomerular filtration rate and albuminuria for detection and staging of acute and chronic kidney disease in adults: a systematic review [J]. JAMA, 2015, 313(8): 837-846.
39	Chu R, Li C, Wang S, et al. Assessment of KDIGO definitions in patients with histopathologic evidence of acute renal disease [J]. Clin J Am Soc Nephrol, 2014, 9(7): 1175-1182.
40	Chen S, Tang Z, Xiang H, et al. Etiology and outcome of crescentic glomerulonephritis from a single center in China: a 10-year review [J]. Am J Kidney Dis, 2016, 67(3): 376-383.
41	James M, Bouchard J, Ho J, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury [J]. Am J Kidney Dis, 2013, 61(5): 673-685.
42	Palevsky PM, Liu KD, Brophy PD, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury [J]. Am J Kidney Dis, 2013, 61(5): 649-672.

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Definition, stage, and epidemiology of acute kidney disease

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Definition, stage, and epidemiology of acute kidney disease