肾脏超声导向的AKI早期诊断.pptVIP

RI诊断AKI的准确性优于尿液检测 Intensive Care Med 2011, 37:68-76 52例ICU重症机械通气患者 持续镇静、血流动力学稳定超声监测 D3 ：判断AKI RI诊断价值优于尿钠/尿素排泄分数 RI判断AKI价值优于Cys 28例sepsis+30例多发伤 入ICU D1 Ucys、Scys、RI、sCr D3：AKI分级 D1：Ucys、Scys、RI、sCr两组间均有差异 仅D1的RI是预测D3 AKI的独立危险因素，阈值为0.707 RI 升高=肾血流↓？ J Ultrasound Med 2000; 19:303–314 分析影响因素： RI 不高≠AKI？ 137例septic AKI 动物研究 RVR变化结果并不一致 Nephron Physiol 2006;104:p1–p11 159例septic AKI 动物研究 62%RBF↓，38%不变或↑ AKI与肾脏微循环 CO↓ RBF↓ GFR↓ hyperemic AKI pre- AKI AKI CO正常或↑ RBF正常或↑ RVR ↑ RVR无变化或↓ 入球和出球小动脉扩张失调 微循环障碍： 皮质向髓质分流 体循环 微循环 60岁患者冠脉分流术后继发AKI（stage I），CEU结果 术前 术后 术后变化 Critical Care 2011, 15:157 肾脏超声造影诊断AKI：微循环水平 术后AKI患者：mTT延长，rBV减少，灌注指数下降，提示肾脏局部灌注减少 B型超声 能量多普勒 超声（PDU） 彩色多普勒 血流成像（CDFI） 超声造影（CEU） 肾脏超声导向的AKI诊断 鉴别急慢性、排除梗阻 高危因素 ≤2分可能AKI 低流速血流 RI0.79提示持续性AKI 高流速血流 mTT、rBV提示AKI 临床+动态监测尿量、尿液和血液标本检测 * * ADQI：急性透析质量倡议；AKIN：急性肾损伤网络工作小组； * * * Fig. 1. B-mode ultrasound images of (A) normal kidney, (B) enlarged and echogenic kidney with loss differentiation between cortical, medullary and sinus fat compartments in a case with acute kidney injury, (C) small, slightly echogenic kidney with thin cortex in a patient with chronic kidney disease and (D) normal size but echogenic kidney with a single simple cyst in a patient with chronic kidney disease secondary to diabetic nephropathy. Cortical thickness：鉴别急慢性AKI the brightness of the ultrasound image：说明与周围组织的对比度，如果水肿，表现出来的是低亮度，如果是肾毒性、单克隆肾病等表现出高亮度 * 肾髓质血流占肾脏总血流的45% * Fig. 4. B-mode (A), and contrast-enhanced (B) ultrasound images of the kidney. Note the marked improvement in image quality especially in clear distinction between the cortex and medulla in the contrast enhanced image. This technique can provide useful information on the quantity and pattern of blood flow, volume and velocity to different regions within the kidney tissue. * 持续低机械指数MI=0.1，造影剂同红细胞一样，不出现在血管外，而微气泡则可以自由通过毛细血管，因此可以监测微循环 . 5. Sequential contrast-enhanced images of kidney with frames selected from (A) steady state during infusion of contrast agent, (B) high energy pulse and