肾脏超声导向的早期诊断.pdf

肾脏超声导向的早期诊断心脏超声:监测到治疗心脏功能评估 容量状态评估液体反应性评估、动态监测、休克复苏肺部超声:诊断到治疗ARDS诊断与鉴别气胸、胸腔积液、肺实变肺实变超声图像P1：胸腔积液；C：肺实变：Ao：主动脉肺复张效果评估左图：肺实变。C：肺实变 组织；*:空气支气管征。右图：PEEP 15cm电0后，同肺区出现多条毗邻B线，表明 实变区内气体的渗入。白色箭头:胸膜线，*：B线。Q4 2超声引导下血管穿刺:定位到引导器官灌注:超声从实验到临床肾脏超声:从肾脏灌注到AKI诊断Intensive Care Med(2006)32:1553-1559 DOI 10.1007/s00134-006-0360-xORIGINALNicolas Lerolle Emmanuel Guerot Christophe Faisy Caroline Bornstahi Jean-Luc Diehl Jean-Yves FagonRenal failure in septic shock:predictive value of Doppler-based renal arterial resistive indexClinical Nephrology,Vol.74-No.1/2010(46-52)2010 Dust r i-Ver l ag Dr.K.Feist l e ISSN 0303U3Q.DOI 10.2379/CNUl t r aso und as a diagno st ic t o o l t o dif f er ent iat e acut e f r o m chr o nic r enal f ail ur eC.A.Ozmen1,D.Akin2,S.U.Bil ek1,A.H.Bayr ak1,S.Sent ur k1 and H.Nazar o gl u11 Department of Radiology,2Department of Nephrology,Dicle University School ofMedicine,Divarbakir,TurkeyG Itai Nefrol 2012;29(5):599-615MASTER IN ECOGRAFIA NEFROLOGICALTCOGRAFIA E IL COLOR-DOPPLER IN NEFROLOGIA.NIH PublAuthor ManusLA MALATTIA RENALE ACUTAMario Meola1-2,Ilaria Petrucci12Published in final edited form as:Curr Drug Targets.2009 December;10(12):11841189.Novel Imaging Techniques in Acute Kidney InjuryAKI的诊断 KIDIGO诊断标准：ADQI推荐RIFLE分级Risk，Incr eased cr eat ininex 1.5 o r GFR decr ease 25%Injur yIncr eased cr eat ininex2 o r GFR decr ease 50%Fail ur eIncr ease cr eat ininex3 o r GFR decr ease 75%UO0,3ml/kg/h x24 hr o r Anur ia x 12 hr sUO 0.5ml/kg/h x12hrUO 4 weeksEnd St age Kidney DiseaseESKD(3 mo nt hs)_ _、AKIN诊断标准SCr标准Ji期增加226.4呵）l/l（0.3mg/dl）或增至基线的 150-200%（1.5-2 倍）尿量g/hr 时间 6h12h2期增至基线的20X300%（2-3倍）3期增至基线的 300%以上(3 倍)或 Scr2354Mmol/l(4mg/dl),24h且急性增加244gmd/l(0.5mg/dl)或无尿12h肌醉(sCr)的局限性与肾功能呈非线性关系年龄、肝功能.容量、营养：GFR下降达6080%(125-25ml/min)血清肌好上升756EC.21BWOOUO。Quc一 lealo EmQsGFR,mL/min per 1.73 m27 PGiuQuc一al。UJruCDsA4 CCC尿量(U0)的局限性正常肾脏：少尿是一种生理反应少尿可能提示着一种病理反应AKI:容量调节能力下降，可不表现为少尿GFR明显降低才表现出少尿生物标记物Loop of Henle:RAP(in rats)Distal tubule:a-GSTGFR:Cystatin Hepcidin L-AFBPProx tubule:LDH NAG 3-galactosidase y-glutamyl transferase NGAL KIM-I a-microglobulin Interleukin 18s 一3 一方布0:AKI早期诊断 RRT指证 评价严币:度及预后 易检测、快速、易解 读 鉴别AKI类型 判断损伤部位 灵敏度和特异度高,鉴别诊断理想的AKI诊断生物标记物tr L 0 传统检测开始RRTOngo ing Injur yInit ial RenalLAKI的治疗时机2012年KIDIGO指南强调:防和保护!_KIDIGOAKI诊断顺序Pre-AKI肾脏灌注不.足 3d内恢复输尿管或肾、盂结石、积,水3d仍未恢J肾脏超声肾脏址流III肾脏超声诊断方法慢性肾脏病B型超声肾脏形态、大小、皮髓质厚度 肾盂积水、结石、囊肿排除梗阻正常肾脏超声急性肾损伤糖尿病肾病Cur r Dr ug Tar get s,2009 December;10(12):1184-1189s彩色多普勒血流成像(CDFI)监测肾脏段与叶的血流EfferentArcuate artery and veinInterlobular artery and veinRT S E GProximal convoluted tubule弓形动脉与叶间动脉RenalRenal veinCortexMedullaLoop of HenleCollecting ductPeritubular capillary networkGlomerularc.p-.um0条artcnolc+Tomps Sys Dias Sys/Dia IR0,193 s41.9 cm/s11.0 cm/sRenalDistal tuDulePulsatility index(PI)=(Vs-Vd)/Vm(O.6 1)Resistive index:RI=(VsVd)/Vs(NSO、70)PI与RI相关性好J=0、92PI的变异率大于Rl：922%vs 4-7%PI和RI反映肾脏血流和肾血管阻力Glomerular capillary pressure:Blood pressure in the glomerular capillary moves fluid、from the blood into Bowmans capsuleCapsule pressure:Pressure in Bowman s capsule moves fluid from Bowmans capsule into the glomerular capillary休克、sepsis.创伤coFIBlood colloid osmotic pressure:The blood protein concentration moves fluid from Bowmans肾血管阻力(RVR)TRI监测肾脏血流多发伤的超声规范化流程:focus assessment sonogr叩hy for trauma(FAST)无失血性休克 失血性休克RI=0、55 R|=0s 83肾皮质血流减少肾皮质血流正常RI测量步骤腹部超声（探头）B超,侧腹部，肾脏长轴彩色多普勒确定肾脏血管采样门:定位弓形动脉或叶间动脉i勒设置:最小采样窗重 复频率最低;增益最大算RI平均值测量对侧肾脏Int ensive Car e Med(2012)38:1751 舞6二彩色多普勒血流成像技术要求患音体位同侧肾脏（右侧）冠状横断面确定肾门采样门：超声束 与血流夹角小呼吸、深部 组织影响技术要求高能量多普勒(PDU)利用血液中红细胞的能量来显示血流信号彩色信号的颜色和亮度代表多普勒信号的能量能量大小与产生多普勒频移的红细胞数量有关PDU不受血流方向及血流与声束夹角的影响尤其适用于低能量、低流速血流的检测PDU评价肾脏灌注2D超声找到最 大仔长轴和短 轴切面行能量多普勒 显像获得最佳的血 流图像患者采纳平卧位蒙侧腹的取冠状面和横断面2分PDU半定量4级评分标准评分0检查不到肾脏血管1分 肾门可见少许血管2分 大部分肾实质内可见叶间血管3分 整个肾脏可见肾血管至弓状动脉水平肾脏超声造影（CEU）通过外周静脉（肘静脉）注入造影剂（微气泡）微泡所在部位回声信号增强（改变超声波与组织间的吸收、反射、折射和散射等）通过时间强度曲线、曲线下面积.平均通过时间反映肾脏血流灌注变化评价肾脏微循环（小叶间与毛细血管）反映肾皮质与髓质灌注XOCOO皮质Contrast-enhanced ultrasound images.3 AOI have been drawn in the outer cortex髓 质外带 Outer zone内带 Inter zone近髓肾单位 Juxtamedullary nephronaeuB&nqop2u-arWB2809 小叶间动脉7弓嚼脉皮质肾单位/Cortical nephron一直小血管Vasa rectaThin segment-薄壁段Thin segment集合管CoHecling duelConventional B-mode ultrasound imagesTar aet s.2009;10(12)d41a89.%!肾脏超声造影评价肾脏灌注A:注射造影剂后 约2min达稳态C:造影剂从肾组织中 清除后，微气泡再现Mean transit time(mTT)动态、定量B:高能量脉冲，微气泡在肾组织内破坏D:微气泡依次出现在 肾段、弓形动脉、叶间 动脉和毛细血管Relative blood volume(rBV)Cur r Dr ug Tar get s、,2009;10(12)*g璃对.金1多普勒超声技术临床价值安全、无创、可靠评估AKI风险血流动力学监测及目标 增强超声：微循环肾脏灌注PDU诊断AKI 3354 中华医学杂志 2012 年12 月 18 日第 92 卷第 47 期 Natl Med J China,December 18 2)12,Vol.92,No.47,临床研究，能量多普勒超声对急性肾损伤的评估价值陈秀凯黄立锋王小卒邱占军张宏民李文雄首都医科大学附属北京朝阳医院外科ICU诊断AKI的40例患者依照2012年KIDIGO诊断标准分级血流动力学稳定6h内超声检查2期 3叫4-J Q 叨|1 分q 2 分 3 3%二|,1 分。CDFI测定RI鉴别ARF原因 91例ARF患者 排除慢性肾功能不全 诊断ARF24h内超声检测Relationship of Creatinine Level and RI to Type of ARF in 91 PatientsMeanType of ARFflMean RI fSDCreatinine Level SD(mg/dL),Examinations with RI .75(%)ATN46.85 063.3 1.391Pre renal30.67 092.6 士 1.320Intrinsic renalfailure(non-ATN)15.74 .134.1 2.447Radiology 1991;179:419-423RI早期预测septic AKI35例septic shock患者入 ICUD1:CDFI(RI)MAP60mmHg(多巴胺或NE)D5:AKI(RIFLE)(Par amet er s at incl usio nNon-AKImaAKIPI718I RI0.69 ro.0810.78 ro.osi0、74,D5发生AKI阳性估计3、3(95%CI Q 135)ri诊断持续性AKI 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灵敏度92%播异度85%8765432179 77777777X6 oooooooo O0.770.72no AKI 暂时AKI 持续AKIRI0.795是诊断持续性AKI的阈值Int entWine et aisRI诊断AKI的准确性优于尿液检测1.0 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AKI0.4 0.20.6 _0.0 0.0 0.2 0.4 0.6 0.81-Specif icit y1.02MWU8SRI诊断价值优于尿钠/尿素排泄分数Int ensive Car e Med 2011*6 福丁RI判断AKI价值优于CysD1:Ucys、Scys、RL sCr两组间均有差异AKIO 1AKI 2-3P 28例sepsis+30例多发伤入ICU D1 Ucys、Scys、RI、sCrPat ient s,nAge,ySAPS IISepsis,n(%)MAP,mmHgAr t er ial l act at e,mmo l/LCat echo l amine,n(%)Mechanical vent il at io n,n(%)4035(22-51)24(14 40)17(43)80(72 90)1.8(1.6 2.8)18(45)19(48)1858(50 69)51(35 58)11(61)77(66 83)4.0(1.9 10.8)15(83)16(89)0.00240.00010.30.080.00110.0150.0071D3:AKI分级SCr,pmo l/L72(60-92)124(85-191)0.0001SCr cl ear ance,mL/min per m2 Ur ine o ut put,mL/h109(67-148)54(37 88)24(16 60)42(7 52)0.00120.075SCys,mg/L0.68(0.57-0.78)1.23(0.85 2.02)0.0002SCys cl ear ance,mL/min per m2125(105 157)57(32 93)0.0002UCys,mg/L0.09(0.04 0.5)3.32(0.1-14.7)0.0008RI0.66(0.62-0.70)0.80(0.72-0.82)0.0001Cut o f f val ueOdds r at io(95%Cl)Univar iat e l o gist ic r egr essio n PAUCMul t ivar iat e l o gist ic r egr essio n PSCr107 pmo l/L1.04(1.01-1.06)0.00160.826NSCr eat inine cl ear ance D10.95(0.91 0.99)0.00880.897NSSCys0.8 mg/L11.34(1.86 69.32)0.00860.837NSCyst at in C cl ear ance D1一0.97(0.95 0.99)0.00120.836NSUCys1.28 mg/L1.34(0.996 1.81)0.05340.761NSRenal RI0.70713.90(3.24 59.59)0.00040.9100.0004Sepsis vs.po l yt r aumaNA0.47(0.15-1.47)0.19320.593NS仅D1的RI是预测D3 AKI的独立危险因素,阈值为0、707SHOCK,Vol.38,No.6,pp.592-597,2012RI升高=肾血流17 分析影响因素:2000;19:303-314感谢您的聆听!