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儿童急性肾损伤的临床特征、病因、评估和诊断

Author
Prasad Devarajan, MD
Section Editor
Tej K Mattoo, MD, DCH, FRCP
Deputy Editor
Melanie S Kim, MD
Translators
钟旭辉, 副主任医师

引言

急性肾损伤(acute kidney injury, AKI)是指肾功能突然丧失，从而导致肾小球滤过率(glomerular filtration rate, GFR)降低、尿素和其他含氮废物潴留，以及细胞外容积和电解质失调。术语AKI已基本上取代了“急性肾功能衰竭(acute renal failure, ARF)”，因为前者更明确地将肾功能不全定义为肾功能下降的连续性表现，而不是间断性表现。儿科AKI的临床表现多种多样，从血清肌酐极轻微增加到无尿性肾衰竭不等，其病因也多样，可发生在多种不同的临床情境下[1-7]。

本专题将总结儿童AKI的病因、临床表现和诊断。儿童AKI的预防、处理和结局以及新生儿AKI的概述参见其他专题。 (参见“儿童急性肾损伤(急性肾衰竭)的预防和处理”和“新生儿急性肾损伤(急性肾衰竭)”)

定义

AKI定义为GFR下降，传统上表现为血清肌酐较基线水平已经升高或正在升高。然而，血清肌酐检测往往有一定延迟且不精确，因为它反映的是状态稳定(肾功能稳定)个体的GFR值，所以对于肾功能状态正在变化的患者，血清肌酐并不能准确反映其GFR水平。例如，一名处于重症AKI早期阶段(GFR显著减少)的儿童，其血清肌酐水平可能相对正常或轻度升高，因为还没有足够的时间让肌酐在体内累积。此外，肌酐能通过透析去除；因此，一旦开始透析，则不可能再采用血清肌酐来评价肾功能。尽管存在上述局限性，血清肌酐已经升高或正在升高仍然是诊断儿童AKI应用最广的实验室指标。 (参见下文‘诊断’)

血清肌酐不能准确反映肾功能这一问题尤其困扰儿科AKI的临床研究。其致使临床研究中使用了35种以上的AKI定义，从血清肌酐的轻微变化到需要透析治疗等等。由于缺乏统一的定义，人们难以在不同的研究间进行比较，致使AKI儿科文献中引用的流行病学、并发症发病率和死亡率数据存在很大差异[8]。使用最广泛的儿科AKI标准化定义为儿科RIFLE(pediatric RIFLE, pRIFLE)、AKI网络协作组(AKI Network, AKIN)和改善全球肾脏病预后组织(Kidney Disease Improving Global Outcomes, KDIGO)的分类标准。 (参见“急性肾损伤(急性肾衰竭)的定义”)

pRIFLE — pRIFLE是成人RIFLE分类标准的儿科修订版，包含3个肾损伤分级(危险、损伤和衰竭)和2个结局指标(肾功能丧失和终末期肾脏病)，其中前者根据估计肾小球滤过率(estimated glomerular filtration rate, eGFR)的变化(如，血清肌酐的变化)幅度或尿量进行分级(表 1)[9]。成人和儿科分类标准之间的差异包括：

                                        

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Literature review current through: 2017-06 . | This topic last updated: 2017-05-16.
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