急性肾损伤诊疗指南解读教材课件.ppt

1、急性肾损伤诊疗指南解读 ADQI：2002,RIFLE AKIN：2005,modified definition and staging system KDIGO:2011,First clinical guideline for AKI Waiting for published in this summer AKI guideline for AKI:2011 AKI guidlineKDIGO 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury 患病率：1%（社区）7.1%（医院）人群发病率：486630 pmp

2、/y AKI需要RRT发病率：22203pmp/y 医院获得AKI死亡率：1080%合并多脏器功能衰竭死亡率：50%需要RRT治疗者死亡率：高达80%符合以下情况之一者即可被诊断为AKI：48小时内Scr升高超过26.5mol/L(0.3 mg/dl)；Scr 升高超过基线1.5倍确认或推测7天内发生；尿量0.5 ml/（kgh），且持续6小时以上。单用尿量改变作为判断标准时，需要除外尿路梗阻及其它导致尿量减少的原因采用KDIGO推荐的定义和分期标准Initiate RRT emergently when life-threatening changes in fluid,electrolyt

3、e,and acid-base balanceexist.RESEARCH RECOMMENDATION：We recommend further trials of ANP at doses below 0.In the treatment of systemic mycoses or parasitic infections,we recommend using azole antifungal agents and/or the echinocandins rather than conventional amphotericin B,if equal therapeutic effic

4、acy can be assumed.采用KDIGO推荐的定义和分期标准Meta-analysis:low-dose dopamine increases urine output but does not prevent renal dysfunction or death.监测乳酸和碱剩余水平control on all-cause mortality.AKI is defined as any of the following(Not Graded):AKI is defined as any of the following(Not Graded):KIncrease in SCr b

5、y X 0.Overlapping ovals show the relationships among AKI,AKD,and CKD.discontinuation of RRT in AKI is not evident.We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with,or at risk for AKI.NAC for prevention of postsurgical AKI.5倍确认或推测7天内发生；具有高出血风险的患者可采取

6、无抗凝剂、盐水冲洗的方法，但引起超滤量增加，透析效率下降及增加了透析膜破裂的风险(2C)慎用高分子量羟乙基淀粉1m g/kg/min,for the prevention or treatment of AKI.Meta-analysis:low-dose dopamine increases urine output but does not prevent renal dysfunction or death.1 详细的病史采集和体格检查有助于AKI病因的判断(1A)GFR60ml/min/1.2评估容量状态后适当补液(1B)AKI分期标准指南推荐血清肌酐和尿量仍然作为AKI最好的标志物(

7、1B)2002 2002 年急性透析质量倡议组年急性透析质量倡议组(ADQI)(ADQI)制定了制定了ARFARF的的 RIFLE RIFLE 分级诊断标准。分级诊断标准。Bellomo R,et al.Crit Care 2004;8:R204-R212Conceptual model for AKI2.1 详细的病史采集和体格检查有助于AKI病因的判断(1A)2.2 24小时之内进行基本的检查，包括尿液分析和泌尿系超声(怀疑有尿路梗阻者)(1A)Definition and staging of AKI 符合以下任何一项 AKI,符合AKI定义 3个月内在原来基础上，GFR下降35%或Sc

8、r上升50%GFR60ml/min/1.73m2,3个月 肾损伤3个月肾功能改变肾功能改变肾脏结构改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR 3个月 3个月AKDAKI3个月内在原来基础上，GFR下降35%或Scr上升50%GFR60ml/min/1.73m2,3个月75岁CKD(eGFR60ml/min/1.73m2心力衰竭动脉粥样硬化性周围血管病变肝脏疾病糖尿病肾毒性药物的使用低血容量感染3.2评估容量状态后适当补液(1B)HIGHRISK3.3造影剂肾病3.4继发于横纹肌溶解的AKI给予0.9%氯化钠和碳酸氢钠扩容(1B)对具对具CI-A

9、KI高风险者：高风险者：建议采用等渗或低渗造影剂建议采用等渗或低渗造影剂 建议口服或静脉使用建议口服或静脉使用N-乙酰半胱氨酸（乙酰半胱氨酸（NAC）及等渗晶体预防）及等渗晶体预防CI-AKI 推荐使用等渗氯化钠或碳酸氢钠静脉扩容以预防推荐使用等渗氯化钠或碳酸氢钠静脉扩容以预防CI-AKI一般治疗(1A)Chapter 2.3:Evaluation and general management ofpatients with and at risk for AKIGFR60ml/min/1.We recommend not using low-dose dopamine toprevent o

10、r treat AKI.discontinuation of RRT in AKI is not evident.control on need for RRT.KDIGO Clinical Practice Guideline for Acute Kidney InjuryMeta-analysis:low-dose dopamine increases urine output but does not prevent renal dysfunction or death.Crit Care 2004;8:R204-R2125 g/kg/d in patients with AKI on

11、RRT(2D),and up to a maximum of 1.BMJ 2006;333(7565):420-4255 ml/（kgh），且持续6小时以上。This will usually require a higher prescription of effluent volume.2评估容量状态后适当补液(1B)Effect of furosemide vs.监测乳酸和碱剩余水平Mehta RL,Pascual MT,Soroko S et al.a renal referral？Friedrich JO,Adhikari N,Herridge MS.discontinuation

12、of RRT in AKI is not evident.根据患者病情和RRT模式制定抗凝治疗方案(1C)(Not Graded)he cause of AKI should be determined whenever possible.(ANP)to prevent(2C)or treat(2B)AKIIn the absence of hemorrhagic shock,we suggest using isotonic crystalloids rather than colloids(albumin orstarches)as initial management for expan

13、sion ofintravascular volume in patients at risk for AKI or with AKI.(2B)We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with,or at risk for AKI.(1C)We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent develop

14、ment or worsening of AKI in high-risk patients in the perioperative setting(2C)or in patients with septic shock(2C)补液治疗：低血容量者：重复小剂量补液(250ml晶体液/胶体液）密切监测CVP和尿量 监测乳酸和碱剩余水平严重脓毒血症者：慎用高分子量羟乙基淀粉 药物治疗(1B)多脏器功能衰竭 药代动力学改变（分布容积、清除、与蛋白结合）需要调整药物剂量需要调整药物剂量目前无特殊的药物用于治疗继发于低灌注损伤/脓毒血症的AKI(1B)袢利尿剂againstMehta RL,Pascu

15、al MT,Soroko S et al.Diuretics,mortality,and nonrecovery of renal function in acute renal failure.JAMA 2002;288:2547-2553 Ho KM,Sheridan DJ.Meta-analysis of frusemide to prevent or treat acute renal failure.BMJ 2006;333(7565):420-425 We recommend not using diuretics to prevent AKI.(1B)We suggest not

16、 using diuretics to treat AKI,exceptin the management of volume overload.(2C)Effect of furosemide vs.control on all-cause mortality.Reprinted from Ho KM,Power BM.Benefits and risks of furosemide in acute kidney injury.Anaesthesia 2010;65:283293 with permission from John Wiley and Sons193;Effect of f

17、urosemide vs.control on need for RRT.Reprinted from Ho KM,Power BM.Benefits and risks of furosemide in acute kidney injury.Anaesthesia 2010;65:283293 with permission from John Wiley and Sons193;Ann Intern Med 2005;142:510-5242评估容量状态后适当补液(1B)医院获得AKI死亡率：1080%导管仅限于RRT治疗时使用(1D)以预防感染(Not Graded)7天内血肌酐升高5

18、0%Meta-analysis:low-dosedopamine increases urine output but does not prevent renal dysfunction or death.急性肾损伤诊疗指南解读危重病人伴有AKI时CRRT与IHD的利弊We suggest not using NAC to prevent AKI in critically ill patients with hypotension.Meta-analysis:low-dose dopamine increases urine output but does not prevent rena

19、l dysfunction or death.a beneficial role for loop diuretics in facilitating根据患者病情和RRT模式制定抗凝治疗方案(1C)05 mg/kg/min)in patients prophylactically or with early AKI,and during a longer period than in previous large studie；Mehta RL,Pascual MT,Soroko S et al.肾脏科与ICU医生协作肾脏科与ICU医生协作We recommend not using oral

20、 or i.Overlapping ovals show the relationships among AKI,AKD,and CKD.ADQI：2002,RIFLE At present,thecurrent evidence does not suggest that furosemide can reduce mortality in patients with AKI.a beneficial role for loop diuretics in facilitatingdiscontinuation of RRT in AKI is not evident.mannitol is

21、not scientifically justified in the prevention of AKI.We recommend not using low-dose dopamine toprevent or treat AKI.（1A）We suggest not using fenoldopam（非诺多巴）to prevent or treat AKI.(2C)We suggest not using atrial natriuretic peptide(ANP)to prevent(2C)or treat(2B)AKIEffect of low-dose dopamine on m

22、ortality.Reprinted from Friedrich JO,Adhikari N,Herridge MSet al.Meta-analysis:low-dosedopamine increases urine output but does not prevent renal dysfunction or death.Ann Intern Med 2005;142:510524 with permissionfrom American College of Physicians212；多巴胺-不建议Friedrich JO,Adhikari N,Herridge MS.Meta-

23、analysis:low-dose dopamine increases urine output but does not prevent renal dysfunction or death.Ann Intern Med 2005;142:510-524 降低肾灌注(Lauschke,Kidney Int 2006)导致心律失常(Schenarts,Current Surgery 2006)加重心肌、肠道缺血缺氧(Schenarts,Current Surgery 2006)非诺多巴-不建议选择性多巴胺A1受体激动剂，在降低全身血管阻力的同时增加肾血流量RESEARCH RECOMMEND

24、ATION：We recommend further trials of ANP at doses below 0.1m g/kg/min,for the prevention or treatment of AKI.There is a possibility that ANP might be effective if it isgiven at a lower dose(0.010.05 mg/kg/min)in patients prophylactically or with early AKI,and during a longer period than in previous

25、large studie；In critically ill patients,we suggest insulin therapy targeting plasma glucose 110149 mg/dl(6.18.3 mmol/l).(2C)We suggest achieving a total energy intake of 2030 kcal/kg/d in patients with any stage of AKI.(2C)We suggest to avoid restriction of protein intake with the aim of preventing

26、or delaying initiation of RRT.(2D)We suggest administering 0.81.0 g/kg/d of protein in non catabolic AKI patients without need fordialysis(2D),1.01.5 g/kg/d in patients with AKI on RRT(2D),and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy(CRRT)and in hypercataboli

27、c patients.(2D)We suggest providing nutrition preferentially via the enteral route in patients with AKI.(2C）2，或者进行每日透析(1B)由经验丰富的医生负责置管(1A)2002 年急性透析质量倡议组(ADQI)制定了ARF的 RIFLE 分级诊断标准。Meta-analysis:low-dose dopamine increases urine output but does not prevent renal dysfunction or death.RESEARCH RECOMMEN

28、DATION：We recommend further trials of ANP at doses below 0.Reprinted from Friedrich JO,Adhikari N,Herridge MSet al.Guideline 2：临床评估采用KDIGO推荐的定义和分期标准Ann Intern Med 2005;142:510524 with permissionfrom American College of Physicians212；About AKI guidelineGFR3周：建议用皮下隧道导管 导管仅限于RRT治疗时使用(1D)以预防感染l根据患者病情和RR

29、T模式制定抗凝治疗方案(1C)l推荐枸橼酸局部抗凝降低出血风险(2C)l具有出血风险的患者可选择前列环素抗凝，但会引起血流动力学不稳定(2C)l具有高出血风险的患者可采取无抗凝剂、盐水冲洗的方法，但引起超滤量增加，透析效率下降及增加了透析膜破裂的风险(2C)难以纠正的电解质紊乱:低钠血症、高钠血症或高钙血症We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patie

30、nts in the perioperative setting(2C)or in patients with septic shock(2C)Overlapping ovals show the relationships among AKI,AKD,and CKD.5 ml/（kgh），且持续6小时以上。慎用高分子量羟乙基淀粉We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours.Glycemic c

31、ontrol and nutritional supportWe suggest not using aminoglycosides for the treat-ment of infections unless no suitable,less nephro-toxic,therapeutic alternatives are available.Anaesthesia 2010;65:283293 with permission from John Wiley and Sons193;(Not Graded)In the treatment of systemic mycoses or p

32、arasitic infections,we recommend using azole antifungal agents and/or the echinocandins rather than conventional amphotericin B,if equal therapeutic efficacy can be assumed.Guideline 2：临床评估(Not Graded)Reprinted from Friedrich JO,Adhikari N,Herridge MSet al.We recommend not using recombinant human(rh

33、)IGF-1 to prevent or treat AKI.3周：建议用皮下隧道导管ADQI：2002,RIFLEAKI guideline for AKI:201105 mg/kg/min)in patients prophylactically or with early AKI,and during a longer period than in previous large studie；AKI guidlineKDIGO 2012l通过对RRT剂量的评估确保透析充分性(1A)l每次(IHD）或每日（CRRT)评估透析剂量及充分性(1A)l推荐伴有多器官功能衰竭的AKI患者行CRRT

34、，后稀释法超滤率25ml/kg/hr。前稀释法的持续性血液滤过相应的上调超滤率(1A)l伴有多器官功能衰竭的AKI患者行间歇性血液透析治疗治疗时，必须达到单次透析URR 65%或eKt/V 1.2，或者进行每日透析(1B)We recommend delivering an effluent volume of 2025 ml/kg/h for CRRT in AKI(1A).This will usually require a higher prescription of effluent volume.(Not Graded)顽固性高钾血症顽固性高钾血症6.5mmol/L血尿素氮血尿素氮

35、27mmol/L难以纠正的代谢性酸中毒难以纠正的代谢性酸中毒PH7.15难以纠正的电解质紊乱难以纠正的电解质紊乱:低钠血症、低钠血症、高钠血症或高钙血症高钠血症或高钙血症肿瘤溶解综合症伴有的高尿酸血症肿瘤溶解综合症伴有的高尿酸血症和高磷酸盐血症和高磷酸盐血症尿素循环障碍和有机酸尿症导致的尿素循环障碍和有机酸尿症导致的高氨血症和甲基丙二酸血症高氨血症和甲基丙二酸血症尿量尿量0.3 ml/kg/h 持续持续24h或者无尿或者无尿12hAKI伴有多器官功能衰竭伴有多器官功能衰竭难以纠正的容量负荷过重难以纠正的容量负荷过重累及终末器官：心包炎，脑病，神经病变，累及终末器官：心包炎，脑病，神经病变，肌病

36、和尿毒症出血肌病和尿毒症出血需要输注血制品和静脉营养需要输注血制品和静脉营养重度中毒或药物过量重度中毒或药物过量严重的低体温或高体温严重的低体温或高体温临床适应症临床适应症生化指标适应症生化指标适应症RRTRRT开始指征开始指征 (1B)(1B)Initiate RRT emergently when life-threatening changes in fluid,electrolyte,and acid-base balanceexist.(Not Graded)“早”：定义不统一 BUN21.5mmol/L（创伤后），或者尿量100ml/8小时（心脏手术后）达到下列指标12小时内进行R

37、RT：尿量30/h持续6小时 Ccr27mmol/L开始RRT，死亡风险翻倍Definition and staging of AKIGuideline 2：临床评估Effect of furosemide vs.Meta-analysis:low-dosedopamine increases urine output but does not prevent renal dysfunction or death.CI-AKI:预防对比剂急性肾损害(Not Graded)CRRT与IHD相比具备以下优点：a beneficial role for loop diuretics in facil

38、itatingWe suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting(2C)or in patients with septic shock(2C)密切监测CVP和尿量9%氯化钠和碳酸氢钠扩容(1B)KDIGO Clinical Practice Guideline for Acute Kidne

39、y InjuryMehta RL,Pascual MT,Soroko S et al.慎用高分子量羟乙基淀粉discontinuation of RRT in AKI is not evident.In the treatment of systemic mycoses or parasitic infections,we recommend using azole antifungal agents and/or the echinocandins rather than conventional amphotericin B,if equal therapeutic efficacy can be assumed.难以纠正的容量负荷过重2评估容量状态后适当补液(1B)1m g/kg/min,for the prevention or treatment of AKI.(Not Graded)BMJ 2006;333(7565):420-425 CRRT与IHD相比具备以下优点：稳定的血流动力学，缓慢、连续性清除液体和溶质，溶质清除率高;持续稳定地控制氮质血症及电解质和水盐代谢;清除炎症介质，能够不断清除循环中存在的毒素和中小分子物质;改善营养支持，保障营养补充及药物治疗,维持内环境稳定。缺点：花费大，机器昂贵，需要专业的医护团队，治疗期间不能外 出治疗、检查等。