Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
Nephron. 2018;140(2):105-110. doi: 10.1159/000490500. Epub 2018 Jun 26.
Acute kidney injury (AKI) is a frequent complication of both cardiac and major non-cardiac surgery. AKI is independently associated with morbidity, mortality, and long-term adverse events including chronic kidney disease in postsurgical patients. Since specific treatment options for kidney failure are very limited, early identification, diagnosis, and renal support strategies are key steps to improve patients' outcome.
According to current Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, AKI diagnosis is based on 2 functional markers, serum creatinine increase and urine output decrease, that are not renal-specific and have important limitations. However, preoperative risk stratification for postoperative AKI and/or early diagnosis after surgery could be the best way to apply preventive or timely supportive therapeutic measures. Clinical prediction scores, renal functional reserve assessment, and new biomarkers of kidney stress (suppression of tumorigenicity-2, insulin-like growth factor binding protein-7, tissue inhibitor metalloproteinase-2) may help the clinicians to identify patients at risk of AKI and that could benefit from the application of nephroprotective bundles suggested by the KDIGO guidelines. In severe AKI patients with oligoanuria and fluid accumulation, renal replacement therapy is the only supportive measure even if mode and timing remain open to investigation. Key messages: Perioperative AKI is an important and underdiagnosed complication. Identifying patients at high risk of AKI and diagnosing AKI early are major goals. Preventive interventions are mainly based on the KDIGO guidelines and bundles. Furthermore, a personalized multidisciplinary approach should always be considered to minimize the progression of disease and the complications related to kidney damage.
急性肾损伤（AKI）是心脏和非心脏大手术的常见并发症。在术后患者中，AKI 与发病率、死亡率以及包括慢性肾脏病在内的长期不良事件独立相关。由于针对肾衰竭的具体治疗方案非常有限，因此早期识别、诊断和肾脏支持策略是改善患者预后的关键步骤。
根据目前的肾脏病：改善全球预后（KDIGO）指南，AKI 的诊断基于 2 个功能标志物，即血清肌酐升高和尿量减少，这两个标志物是非肾脏特异性的，具有重要的局限性。然而，术后 AKI 的术前风险分层和/或术后早期诊断可能是应用预防性或及时支持性治疗措施的最佳方法。临床预测评分、肾功能储备评估和新的肾脏应激生物标志物（肿瘤抑制因子-2、胰岛素样生长因子结合蛋白-7、组织金属蛋白酶抑制剂-2）可以帮助临床医生识别发生 AKI 风险的患者，这些患者可能受益于 KDIGO 指南建议的肾脏保护措施。在少尿和液体蓄积的严重 AKI 患者中，肾脏替代治疗是唯一的支持措施，即使模式和时机仍有待研究。
围手术期 AKI 是一种重要且未被充分诊断的并发症。确定 AKI 高危患者并早期诊断 AKI 是主要目标。预防干预主要基于 KDIGO 指南和肾脏保护措施。此外，还应始终考虑采用个性化的多学科方法，以最大程度地减少疾病的进展和与肾脏损伤相关的并发症。
