Kalra P A
Department of Renal Medicine, Hope Hospital, Salford, UK.
EDTNA ERCA J. 2002;Suppl 2:34-8, 42. doi: 10.1111/j.1755-6686.2002.tb00254.x.
Despite major advances in nutritional support, membrane technology and dialytic techniques, the mortality of patients with acute renal failure (ARF) who require dialysis is still almost 50% (1). Increased patient age and co-morbidity confer a poorer prognosis, and the condition is certainly commoner in this patient group. Hence, one study showed that the age-related annual incidence of ARF increased from 17 per million in adults under 50 years to 949 per million in the 80-89 age group (2). Over 60% of cases of ARF ultimately result from renal hypoperfusion and consequent intra-renal ischaemic damage, which leads to acute tubular necrosis (ATN) (3). Ischaemic ARF may thus result from a diversity of systemic and intra-renal circulatory stresses including acute losses of blood and extra-cellular fluids, from low cardiac output states such as following ischaemic or toxic myocardial damage, and even from drug-induced renal perfusion shutdown (ACE inhibitors, non-steroidal anti-inflammatory agents). Many cases of ARF have a multi-factorial aetiology (e.g. post-surgical sepsis with hypovolaemia, hypotension and injudicious antibiotic use), and these patients, who often have other organ failure, fit into the poorer prognostic category. A large number of patients with ischaemic ARF pass through a phase of potentially reversible pre-renal oliguria; early recognition and prompt, appropriate treatment of these pre-renal factors can prevent progression to established ARF, with the genuine prospect of improved patient morbidity and mortality, and this is the main scope of this article. Early diagnosis in other patients with ARF, such as those with acute inflammatory renal disease (e.g. vasculitis) or urinary tract obstruction, will allow appropriate prompt treatment and the possibility for reversal of the ARF. The following account, which is composed of personal experience, that of colleagues, and the literature (1,4), is not intended to provide a comprehensive guide to the management of ARF, but seeks to highlight important common pitfalls and fundamental principles in the recognition and subsequent preventive treatment of these patients.
尽管在营养支持、膜技术和透析技术方面取得了重大进展，但需要透析的急性肾衰竭（ARF）患者的死亡率仍接近50%（1）。患者年龄增加和合并症会导致预后较差，而且这种情况在该患者群体中肯定更为常见。因此，一项研究表明，ARF的年龄相关年发病率从50岁以下成年人中的每百万17例增加到80 - 89岁年龄组中的每百万949例（2）。超过60%的ARF病例最终是由肾灌注不足及随之而来的肾内缺血性损伤导致的，进而引发急性肾小管坏死（ATN）（3）。缺血性ARF可能由多种全身和肾内循环应激因素引起，包括血液和细胞外液的急性丢失、缺血或中毒性心肌损伤后的低心输出量状态，甚至药物引起的肾灌注中断（血管紧张素转换酶抑制剂、非甾体类抗炎药）。许多ARF病例有多种病因（例如术后败血症合并血容量不足、低血压和不合理使用抗生素），这些患者往往还伴有其他器官衰竭，属于预后较差的类别。大量缺血性ARF患者会经历一个潜在可逆的肾前性少尿阶段；早期识别并及时、恰当地治疗这些肾前性因素可预防进展为确诊的ARF，切实有望改善患者的发病率和死亡率，这也是本文的主要内容。对其他ARF患者，如患有急性炎症性肾病（如血管炎）或尿路梗阻的患者进行早期诊断，将有助于及时进行适当治疗并使ARF有可能逆转。以下内容结合了个人经验、同事的经验以及文献（1,4），并非旨在提供ARF管理的全面指南，而是旨在强调在识别和后续预防性治疗这些患者时重要的常见陷阱和基本原则。
