急性肾损伤诊疗指南解读2012版课件

急性肾损伤诊疗指南解读,KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012,赵良斌,KDIGO：Kidney Disease Improving Global Outcomes,2012-KDIGO指南解读,急性肾损伤(AKI)与急性肾衰竭(ARF),国际肾脏病和急救医学界将ARF 改为急性肾损伤（Acute Kidney Injury, AKI）。 AKI 覆盖的肾损伤,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006 Biesen WV et al. CJASN. 2006,About AKI guideline,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 UK Renal Association Final Version 08.03.11 AKI guidlineKDIGO 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury,AKI流行病学现状,患病率：1%（社区） 7.1%（医院） 人群发病率：486630 pmp/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%,指南推荐强度,指南推荐强度,Guideline 1：AKI的定义与分期,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,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(1B),RIFLE分级,2002 年急性透析质量倡议组(ADQI)制定了ARF的 RIFLE 分级诊断标准。,Bellomo R, et al. Crit Care 2004;8:R204-R212,Conceptual model for AKI,Guideline 2：临床评估,2.1 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),Chapter 2.2: Risk assessment,Chapter 2.2: Risk assessment,AKI is defined as any of the following (Not Graded ): AKI is defined as any of the following (Not Graded ): KIncrease in SCr by X 0.3 mg/dl ( X26.5 lmol/l)within 48 hours; or KIncrease in SCr to X1.5 times baseline, whichis known or presumed to have occurred withinthe prior 7 days; orKUrine volume o0.5 ml/kg/h for 6 hours. Test patients at increased risk for AKI with measurements of SCr and urine output to detect AKI. ( Not Graded ) Individualize frequency and duration of monitoring based on patient risk and clinical course. ( Not Graded ) Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes.(Not Graded ) he cause of AKI should be determined whenever possible. (Not Graded),Definition and staging of AKI,Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.,AKD acute kidney diseases and disorder,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Scr上升50% GFR60ml/min/1.73m2, 3个月 肾损伤3个月,AKI/CKD/AKD,Guideline 3：Prevention and Treatment of AKI,3.1评估危险因素(1B) 年龄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),HIGH RISK,3.3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CI-AKI高风险者： 建议采用等渗或低渗造影剂 建议口服或静脉使用N -乙酰半胱氨酸（NAC）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CI-AKI,Guideline 4：AKI的治疗,一般治疗(1A),Stage-based management of AKI,Chapter 2.3:Evaluation and general management ofpatients with and at risk for AKI,补液治疗,In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion 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 development 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,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,against,Mehta RL, Pascual 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,Chapter 3.4: The use of diuretics in AKI,We recommend not using diuretics to prevent AKI. (1B) We suggest not 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 furosemide 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;,The use of diuretics in AKI,At present, thecurrent evidence does not suggest that furosemide can reduce mortality in patients with AKI. a beneficial role for loop diuretics in facilitating discontinuation of RRT in AKI is not evident.,甘露醇,mannitol is not scientifically justified in the prevention of AKI.,Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides,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) AKI,Effect of low-dose dopamine on mortality. 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-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 RECOMMENDATION：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 large studie；,Glycemic control and nutritional support,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 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 hypercatabolic patients. ( 2D) We suggest providing nutrition preferentially via the enteral route in patients with AKI. (2C）,Growth factor intervention,We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI. （1B）,human IGF-1：重组人胰岛素样生长因子1,Prevention of aminoglycoside- and amphotericin-related AKI,We suggest not using aminoglycosides for the treat-ment of infections unless no suitable, less nephro-toxic, therapeutic alternatives are available. (2A) We suggest that, in patients with normal kidney function in steady state, aminoglycosides are administered as a single dose daily rather thanmultiple-dose daily treatment regimens. (2B) We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A) We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used for more than 48 hours. (2C) We suggest using topical or local applications of aminoglycosides (e.g., respiratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. ( 2B),Prevention of aminoglycoside- and amphotericin-related AKI,We suggest using lipid formulations of ampho-tericin B rather than conventional formulations of amphotericin B. (2A) 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.(1A),Other methods of prevention of AKI in the critically ill,We suggest that off-pump coronary artery bypass graft surgery not be selected solely for the purpose of reducing perioperative AKI or need for RRT. (2C) We suggest not using NAC to prevent AKI in critically ill patients with hypotension. (2D) We recommend not using oral or i.v. NAC for prevention of postsurgical AKI. (1A),CI-AKI:预防对比剂急性肾损害,Guideline 5：医疗资源合理分配,多学科参与AKI指南制定 肾科医生会诊提供专科意见 合理的转诊方案 密切监护治疗 肾脏科与ICU医生协作,When to request a renal referral？,Guideline 6：RRT模式的选择,建议个体化治疗！(1B),Kanagasundaram,2007,Guideline 7： 透析器和透析液的选择,透析器： 合成膜透析器(1B) 改良纤维素膜透析器(1B),透析液： 首选碳酸氢钠透析液/置换液(1C) 透析液微生物的控制,Guideline 8：血管通路,临时建立静脉-静脉通路(1A) 选择足够长度的透析导管以降低再循环率(1B) 置管部位和导管类型需根据患者的病情选择(2C) 由经验丰富的医生负责置管(1A) 实时超声导引有助于置管(1D) 对有进展至CKD4-5期风险的患者，尽量避免行锁骨下静脉置管，保护患者的血管资源(1D),Guideline 8：血管通路,保护非优势侧的上肢血管(2C) 定期更换临时导管以降低感染的风险(1C) 颈内静脉：3周 股静脉：1周 3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,Guideline 9：体外抗凝,根据患者病情和RRT模式制定抗凝治疗方案(1C) 推荐枸橼酸局部抗凝降低出血风险(2C) 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) 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),Guideline 10：RRT处方,通过对RRT剂量的评估确保透析充分性(1A) 每次(IHD）或每日（CRRT)评估透析剂量及充分性(1A) 推荐伴有多器官功能衰竭的AKI患者行CRRT，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) 伴有多器官功能衰竭的AKI患者行