# 一名79歲的個案因腹瀉、經口攝入量減少及濃縮深色尿液持續3天，由長期照護機構入院。護理師查閱近期的檢驗報告。哪項發現最令護理師擔憂早期急性腎損傷，並需要立即通知醫師？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一名79歲的個案因腹瀉、經口攝入量減少及濃縮深色尿液持續3天，由長期照護機構入院。護理師查閱近期的檢驗報告。哪項發現最令護理師擔憂早期急性腎損傷，並需要立即通知醫師？

## 選項

1. 尿比重在24小時內從1.005上升到1.025
2. 血中尿素氮在72小時內從10升至22 mg/dL
3. 血清鈉濃度在48小時內從140降至138 mEq/L
4. 血清肌酸酐於48小時內由基準0.8升至1.3 mg/dL **✔ 正確答案**

**正確答案: 4**

## 解析

KDIGO第1期急性腎損傷：血清肌酸酐在48小時內上升0.3 mg/dL或以上，或在7天內上升至基線值的1.5至1.9倍，或尿量低於0.5毫升/公斤/小時持續6至12小時。這位脫水的老年個案，肌酸酐在48小時內由0.8 mg/dL升至1.3 mg/dL（變化值0.5），符合KDIGO第1期。尿比重1.025及血中尿素氮22僅反映脫水狀態。鈉138 mEq/L在正常範圍內。

## 深入解析

臨床判斷
長者因肌肉量減少基準肌酸酐偏低,即使小幅絕對上升亦代表顯著GFR下降。KDIGO Stage 1 AKI: 48小時內肌酸酐≥0.3 mg/dL 或 7天內1.5-1.9倍。0.5 mg/dL上升為最早可行動指標。

記憶口訣
AKI: 48小時0.3、7天1.5倍、UOP <0.5 mL/kg/h 6小時

韓 vs 美
KDIGO為國際統一標準,臺美韓臨床與考試一致。NCLEX採KDIGO,而非舊版RIFLE。

## 臨床情境

臨床指引
KDIGO 2012 AKI分期:
- Stage 1: 48小時肌酸酐升≥0.3 mg/dL 或 7天1.5-1.9倍、UOP <0.5 mL/kg/h 6-12小時
- Stage 2: 2.0-2.9倍 或 UOP <0.5 mL/kg/h ≥12小時
- Stage 3: ≥3倍、肌酸酐≥4.0、開始RRT、UOP <0.3 mL/kg/h ≥24小時
腎前性AKI初步處置: 等張IV補液,暫停腎毒性藥(NSAID、ACE-I、顯影劑)。

注意
長者基準肌酸酐低,小幅上升仍重要。應依基準值變化判讀,而非絕對值。虛弱長者由0.8升至1.3可能代表GFR下降逾50%。

## 重要概念

- **KDIGO AKI分期** — Kidney Disease: Improving Global Outcomes 2012分期。Stage 1: 肌酸酐基準1.5-1.9倍或48小時內升≥0.3 mg/dL,或UOP
- **腎前性AKI** — 腎臟灌流不足所致AKI(脫水、低血壓、心衰、NSAID)。早期矯正可逆。檢驗特徵: BUN/肌酸酐比>20:1、FENa
- **基準肌酸酐** — 現病前的常態血清肌酸酐。長者因肌肉量減少基準偏低(0.6-0.8),即便絕對上升小亦可能代表大幅GFR降低。應評估趨勢而非單一數值。

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