机械通气与急性肾损伤：从机制到临床实践

doi:10.3877/cma.j.issn.2095-3216.2025.06.007

机械通气与急性肾损伤(acute kidney injury，AKI)的发生发展密切相关，其机制涉及血流动力学改变、炎症介质释放、神经体液系统激活及血气紊乱等多因素综合作用。新型生物标志物(如中性粒细胞明胶酶相关脂质运载蛋白、金属蛋白酶组织抑制剂-2和胰岛素样生长因子结合蛋白7)及机器学习模型有助于AKI的早期预警。本文综述了机械通气相关AKI流行病学、病理生理机制、早期预警及防治策略的研究进展，旨在为此类患者的早期识别、精准诊断和规范治疗提供参考。

关键词: 机械通气, 急性肾损伤, 机制, 生物标志物, 机器学习

Mechanical ventilation is closely related to the occurrence and development of acute kidney injury (AKI). Its mechanism involves a comprehensive interaction of multiple factors, such as hemodynamic changes, release of inflammatory mediators, activation of neurohumoral systems, and blood gas disorders. New biomarkers, such as neutrophil gelatinase-associated lipocalin, tissue inhibitor of metalloproteinase-2, and insulin-like growth factor binding protein-7, along with machine learning models, aid in the early warning of AKI. This article reviewed the research progress on the epidemiology, pathophysiological mechanisms, early warning, and prevention and treatment strategies of mechanical ventilation-associated acute kidney injury (AKI), aiming to provide references for early identification, precise diagnosis, and standardized treatment of such patients.

Key words: Mechanical ventilation, Acute kidney injury, Mechanisms, Biomarkers, Machine learning

表1 不同患者群体中急性肾损伤的发生率及主要风险因素

患者群体	AKI发生率	主要风险因素	参考文献
一般ICU成人患者	17.5%~57.3%	脓毒症、休克	[1]
COVID-19重症患者	49.2%~56%	机械通气、正液体平衡、右心衰竭	[3，4]
A型主动脉夹层术后老年患者	53.3%	较长的术后机械通气时间	[5]
儿科ICU患者	5.9%~18.23%	感染、休克、机械通气	[6]
极低出生体重婴儿	19.5%	早期机械通气、肾毒性药物	[7]

表1 不同患者群体中急性肾损伤的发生率及主要风险因素

患者群体	AKI发生率	主要风险因素	参考文献
一般ICU成人患者	17.5%~57.3%	脓毒症、休克	[1]
COVID-19重症患者	49.2%~56%	机械通气、正液体平衡、右心衰竭	[3，4]
A型主动脉夹层术后老年患者	53.3%	较长的术后机械通气时间	[5]
儿科ICU患者	5.9%~18.23%	感染、休克、机械通气	[6]
极低出生体重婴儿	19.5%	早期机械通气、肾毒性药物	[7]

表2 机械通气相关急性肾损伤的潜在早期生物标志物

生物标志物类别	生物标志物	主要发现与应用价值	参考文献
肾损伤标志物	NGAL、KIM-1、IL-18	在肾损伤后数小时内即可升高，远早于血清肌酐变化，可用于早期诊断和预后评估	[35，36，37]
细胞周期停滞标志物	TIMP-2、IGFBP7	反映肾脏细胞应激，预测AKI风险的敏感性和特异性高，已被美国FDA批准	[14，38，39]
肾功能标志物	胱抑素C	比血清肌酐更早、更精确地反映GFR变化，不受肌肉量等因素影响	[11，40]
其他新型标志物	尿微量元素(镉、铜、锌)	在室温下稳定，具有低成本床旁检测潜力，显示出良好的预测性能	[41]
血流动力学指标	RRI、RrSO₂	无创评估肾脏血流阻力和氧合状态，RRI与PEEP水平及AKI风险相关	[24，42]

表2 机械通气相关急性肾损伤的潜在早期生物标志物

生物标志物类别	生物标志物	主要发现与应用价值	参考文献
肾损伤标志物	NGAL、KIM-1、IL-18	在肾损伤后数小时内即可升高，远早于血清肌酐变化，可用于早期诊断和预后评估	[35，36，37]
细胞周期停滞标志物	TIMP-2、IGFBP7	反映肾脏细胞应激，预测AKI风险的敏感性和特异性高，已被美国FDA批准	[14，38，39]
肾功能标志物	胱抑素C	比血清肌酐更早、更精确地反映GFR变化，不受肌肉量等因素影响	[11，40]
其他新型标志物	尿微量元素(镉、铜、锌)	在室温下稳定，具有低成本床旁检测潜力，显示出良好的预测性能	[41]
血流动力学指标	RRI、RrSO₂	无创评估肾脏血流阻力和氧合状态，RRI与PEEP水平及AKI风险相关	[24，42]

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Mechanical ventilation and acute kidney injury: from mechanisms to clinical practice

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Mechanical ventilation and acute kidney injury: from mechanisms to clinical practice