中国肝移植受者肾损伤管理临床实践指南(2023版)

doi:10.3877/cma.j.issn.1674-3903.2023.06.001

肾损伤是肝移植术后常见并发症，主要包括急性肾损伤和慢性肾脏病。肝移植受者肾损伤严重影响受者长期生存和生活质量，是导致受者术后死亡的主要原因之一。为了规范化和优化肝移植受者肾损伤的诊疗，中华医学会器官移植学分会和中国医师协会器官移植医师分会组织专家在《中国肝移植受者肾损伤管理专家共识(2017版)》的基础上，结合近年来循证医学依据和我国临床实践经验，制订了《中国肝移植受者肾损伤管理临床实践指南(2023版)》，以适应诊疗模式快速发展的新形势。本指南重点阐述肝移植受者肾损伤定义、分类、评估以及术前、术中和术后防治等内容，并科学规范地提出了系列推荐意见，旨在优化我国肝移植受者肾损伤管理。

关键词: 肝移植, 急性肾损伤, 慢性肾脏病, 肾损伤管理

Kidney injury is a common complication after liver transplantation, including acute kidney injury and chronic kidney disease. Kidney injury in liver transplant recipients seriously affects their long-term survival and life quality, and is one of the main causes of death after liver transplantation. In order to standardize and optimize the diagnosis and treatment of kidney injury in liver transplant recipients, Branch of Organ Transplant of Chinese Medical Association and Branch of Organ Transplant Physicians of Chinese Medical Doctor Association organize experts to develop the "Clinical Practice Guidelines for Kidney Injury Management of Liver Transplant Recipients in China (2023 Edition)" to adapt to the rapid development of diagnosis and treatment. The guideline is based on "Chinese expert consensus on management of kidney injury in liver transplant recipients (2017 edition)" and in conjunction with recent evidence-based medicine and clinical practice experience in China. This guideline focuses on the definition, classification, assessment and preoperative, intraoperative and postoperative prevention and treatment of kidney injury in liver transplant recipients. By presenting a series of scientifically standardized recommendations, the guideline is aimed to optimize the management of kidney injury in liver transplant recipients in China.

Key words: Liver transplantation, Acute kidney injury, Chronic kidney disease, Kidney injury management

表1 GRADE证据质量与推荐强度分级系统

项目	具体描述	研究类型
证据质量分级
高(A)	非常有把握：观察值接近真实值	RCT；质量升高二级的观察性研究
中(B)	对观察值有中等把握：观察值有可能接近真实值，但亦有可能差别很大	质量降低一级的RCT；质量升高一级的观察性研究
低(C)	对观察值的把握有限：观察值可能与真实值有较大差别	质量降低二级的RCT；观察性研究
极低(D)	对观察值几乎无把握：观察值与真实值可能有极大差别	质量降低三级的RCT；质量降低一级的观察性研究；系列病例观察；个案报道
推荐强度分级
强(1)	明确显示干预措施利大于弊或弊大于利
弱(2)	利弊不确定或无论质量高低的证据均显示利弊相当

表1 GRADE证据质量与推荐强度分级系统

项目	具体描述	研究类型
证据质量分级
高(A)	非常有把握：观察值接近真实值	RCT；质量升高二级的观察性研究
中(B)	对观察值有中等把握：观察值有可能接近真实值，但亦有可能差别很大	质量降低一级的RCT；质量升高一级的观察性研究
低(C)	对观察值的把握有限：观察值可能与真实值有较大差别	质量降低二级的RCT；观察性研究
极低(D)	对观察值几乎无把握：观察值与真实值可能有极大差别	质量降低三级的RCT；质量降低一级的观察性研究；系列病例观察；个案报道
推荐强度分级
强(1)	明确显示干预措施利大于弊或弊大于利
弱(2)	利弊不确定或无论质量高低的证据均显示利弊相当

表2 急性肾损伤分级标准^[20]

分级	血清肌酐	尿量
1级	1.5～1.9倍基线值，或升高值≥26.5 μmol/L	连续6～12 h<0.5 mL·kg^－1·h^－1
2级	2.0～2.9倍基线值	连续12 h以上<0.5 mL·kg^－1·h^－1
3级	≥3.0倍基线值，或升高值≥353.6 μmol/L，或开始行肾脏替代治疗，或年龄<18岁者估算肾小球滤过率<35 mL·min^－1·(1.73 m²)^－1	连续24 h以上<0.3 mL·kg^－1·h^－1或无尿12 h

表2 急性肾损伤分级标准^[20]

分级	血清肌酐	尿量
1级	1.5～1.9倍基线值，或升高值≥26.5 μmol/L	连续6～12 h<0.5 mL·kg^－1·h^－1
2级	2.0～2.9倍基线值	连续12 h以上<0.5 mL·kg^－1·h^－1
3级	≥3.0倍基线值，或升高值≥353.6 μmol/L，或开始行肾脏替代治疗，或年龄<18岁者估算肾小球滤过率<35 mL·min^－1·(1.73 m²)^－1	连续24 h以上<0.3 mL·kg^－1·h^－1或无尿12 h

表3 慢性肾脏病的GFR分期

GFR分期	GFR[mL·min^－1·(1.73 m²)^－1]	描述
G1期	≥90	正常或偏高
G2期	60～89	轻度下降^a
G3a期	45～59	轻－中度下降
G3b期	30～44	中－重度下降
G4期	15～29	重度下降
G5期	<15	肾衰竭

表3 慢性肾脏病的GFR分期

GFR分期	GFR[mL·min^－1·(1.73 m²)^－1]	描述
G1期	≥90	正常或偏高
G2期	60～89	轻度下降^a
G3a期	45～59	轻－中度下降
G3b期	30～44	中－重度下降
G4期	15～29	重度下降
G5期	<15	肾衰竭

表4 血清肌酐基线值估算方法

方法	评估效能
设定GFR为75 mL·min^－1·(1.73 m²)^－1，应用MDRD公式反推血清肌酐值	特异度低，尤其在CKD患者中^{[31,32,33,34]}
设定GFR为100 mL·min^－1·(1.73 m²)^－1，应用MDRD公式反推血清肌酐值	敏感度非常高，特异度非常低^[34]
入院初查血清肌酐值	特异度低^[33]
住院前7 d内最低血清肌酐值	特异度低^[33]
通过种族、性别和CKD合并症等多重校正方法估算血清肌酐值	特异度高^[32]

表4 血清肌酐基线值估算方法

方法	评估效能
设定GFR为75 mL·min^－1·(1.73 m²)^－1，应用MDRD公式反推血清肌酐值	特异度低，尤其在CKD患者中^{[31,32,33,34]}
设定GFR为100 mL·min^－1·(1.73 m²)^－1，应用MDRD公式反推血清肌酐值	敏感度非常高，特异度非常低^[34]
入院初查血清肌酐值	特异度低^[33]
住院前7 d内最低血清肌酐值	特异度低^[33]
通过种族、性别和CKD合并症等多重校正方法估算血清肌酐值	特异度高^[32]

表5 肝肾联合移植资格标准

诊断	必须满足如下条件之一
GFR≤60 mL·min^－1·(1.73 m²)^－1且持续超过3个月的CKD	(1)定期透析 (2)申请肾移植时最新GFR≤ 30 mL·min^－1·(1.73 m²)^－1。
持续AKI	(1)接受透析超过6周 (2)GFR≤25 mL·min^－1·(1.73 m²)^－1超过6周 (3)上述2个条件的任意组合6周
代谢性疾病	(1)高草酸尿症 (2)H或I因子突变所致的非典型溶血性尿毒症综合征 (3)非神经病性家族遗传性淀粉样变 (4)甲基丙二酸尿症

表5 肝肾联合移植资格标准

诊断	必须满足如下条件之一
GFR≤60 mL·min^－1·(1.73 m²)^－1且持续超过3个月的CKD	(1)定期透析 (2)申请肾移植时最新GFR≤ 30 mL·min^－1·(1.73 m²)^－1。
持续AKI	(1)接受透析超过6周 (2)GFR≤25 mL·min^－1·(1.73 m²)^－1超过6周 (3)上述2个条件的任意组合6周
代谢性疾病	(1)高草酸尿症 (2)H或I因子突变所致的非典型溶血性尿毒症综合征 (3)非神经病性家族遗传性淀粉样变 (4)甲基丙二酸尿症

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Clinical practice guidelines for kidney injury management of liver transplant recipients in China (2023 edition)

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