Acute renal failure definitions and classification: Time for change?
Acute renal failure definitions and classification: Time for change?
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DOI：
10.1097/01.asn.0000079042.13465.1a
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发表时间：
2003-08-01
影响因子：
13.6
通讯作者：
Chertow, GM
中科院分区：
文献类型：
--
作者：
Mehta, RL;Chertow, GM
急性肾功能衰竭(ARF)在医院环境中的发展仍然与不良结局相关(1-7)。在过去的三十年里，几个实验模型已经确定了与ARF相关的病理生理机制，并增强了我们对这种疾病的理解(8-10)。很明显，ARF可由肾血流灌注改变、肾小球滤过改变和肾小管功能障碍引起，纠正这些因素可改善ARF的影响(11，12)。在确定潜在机制的基础上，已经开发了几种新的潜在干预措施，已被证明可以在实验模型中改变早期和已建立的ARF的进程(13-15)。这些发现的应用改善了由于放射造影剂、氨基糖苷类抗生素和横纹肌溶解而导致的ARF的预防(16，17)。其他几种药物现在处于开发的高级阶段或临床试验的初始阶段(18，19)。同时，除了间歇性血液透析和急性腹膜透析外，随着连续性肾脏替代疗法的出现，透析方面也取得了进展(20-22)。众所周知，无并发症的ARF通常可以在重症监护病房(ICU)之外进行治疗，预后良好，死亡率低于5%至10%(23，24)。相反，在ICU环境下ARF并发非肾器官系统衰竭与50%至70%的死亡率相关，这一死亡率几十年来没有变化(6，25-30)。这些数字与急性心肌梗死(AMI)的经历形成鲜明对比，在过去的25到30年里，急性心肌梗死的住院死亡率从50%下降到大约6%。急性心肌梗死预后的改善在很大程度上归功于冠状动脉护理病房、心导管置入术、阿司匹林、肾上腺素能拮抗剂、溶栓治疗的使用，以及最近专门的经皮冠状动脉介入治疗和糖蛋白IIb-IIIa抑制剂(31-34)。尽管改进了透析技术，包括为最危重的患者开发和改进连续肾脏替代疗法，但我们没有看到与ARF相关的高死亡率的实质性变化。事实上，我们还没有证明任何在ARF早期治疗中有效的药物或其他干预措施。已被认为无效(或潜在有害)的干预措施包括：环状和渗透性利尿剂(35，36)、“肾剂量”多巴胺(37，38)、心钠素(39，40)、胰岛素样生长因子-1(41)和内皮素受体拮抗剂(42)。虽然ARF可能发生在5%或更多的住院患者中，但ARF及其相关并发症的异质性使其研究比急性心肌梗死和其他更离散的情况更困难。ARF研究进展的障碍之一是缺乏一个统一的ARF定义，可用于比较和对比观察性研究，并允许合理设计临床试验。相对较少的研究考察了医院获得性ARF的发生率。Hou等人经常引用的研究(23)报告了ARF发病率估计为4.9%。Shusterman等人(24岁)进行了一项类似的研究，在1.9%的住院患者中确定了ARF。侯和他的同事最近发表的一项后续研究(43)显示，发病率增加(7%)，但危险因素的范围相似。重症监护室环境下的ARF在过去20年中也有其特点。Liano等人(6)发现合并ARF的ICU患者有相关的器官衰竭、败血症和其他并发症。IT与…
The development of acute renal failure (ARF) in the hospital setting continues to be associated with poor outcomes (1–7). Over the last three decades, several experimental models have identified pathophysiologic mechanisms associated with ARF and have enhanced our understanding of the disease (8–10). It is evident that ARF can result from alterations in renal perfusion, changes in glomerular filtration, and tubular dysfunction, and that correction of these factors can ameliorate the effects of ARF (11, 12). On the basis of the identification of the underlying mechanisms, several new potential interventions have been developed that have been shown to alter the course of incipient and established ARF in experimental models (13–15). Application of these findings has resulted in improvements in the prevention of ARF due to radiocontrast agents, aminoglycoside antibiotics, and rhabdomyolysis (16, 17). Several other agents are now in advanced stages of development or initial phases of clinical trials (18, 19). In concert, advances in dialysis have occurred with the availability of continuous renal replacement therapies in addition to intermittent hemodialysis and acute peritoneal dialysis (20–22). It is well recognized that uncomplicated ARF can usually be managed outside the intensive care unit (ICU) setting and carries a good prognosis, with mortality rates less than 5% to 10%(23, 24). In contrast, ARF complicating nonrenal organ system failure in the ICU setting is associated with mortality rates of 50% to 70%, which has not changed for several decades (6, 25–30). These figures are in sharp contrast to the experience with acute myocardial infarction (AMI), where in-hospital mortality rates have declined from the range of 50% to approximately 6% over the past 25 to 30 yr. Much of the credit for improved AMI outcomes has been attributed to the use of coronary care units, cardiac catheterization, aspirin,-adrenergic antagonists, thrombolytic therapy, and, more recently, specialized percutaneous coronary interventions and glycoprotein IIb–IIIa inhibitors (31–34). In spite of improved dialytic technology, including the development and refinement of continuous renal replacement therapies for the most critically ill patients, we have seen no material change in the high mortality rates associated with ARF. Indeed, we have not demonstrated any pharmacologic or other intervention effective in the early management of ARF. Interventions that have been deemed ineffective (or potentially harmful) include the following: loop and osmotic diuretic agents (35, 36),“renal dose” dopamine (37, 38), atrial natriuretic peptide (39, 40), insulin-like growth factor-1 (41), and endothelin receptor antagonists (42).Although ARF may develop in 5% or more of hospitalized patients, the heterogeneity of ARF and associated comorbidity make its study more difficult than AMI and other, more discrete conditions. Among the impediments to progress in ARF research is the lack of a uniform definition of ARF that might be used to compare and contrast observational studies, and to allow for rational design of clinical trials. Relatively few studies have examined the incidence of hospital-acquired ARF. The oft-cited study by Hou et al.(23) reported an ARF incidence estimate of 4.9%. Shusterman et al.(24) conducted a similar study identifying ARF in 1.9% of hospitalized patients. A follow-up study recently published by Hou and colleagues (43) showed an increase in incidence (7%), but a similar spectrum of risk factors. ARF in the ICU setting has also been characterized in the last two decades. Liano et al.(6) found ICU patients with ARF to have associated organ failure, sepsis, and other complications. It …