【持续性肾脏替代治疗crrt英文精品课件】acute renal failure, fluid management and renal replacement therapy

Acute Renal Failure, Fluid Management and Renal Replacement Therapy,行政院衛生署桃園醫院 腎臟科 V.S王偉傑,Outline,Renal function Acute renal failure Complication of ARF Management Renal replacement therapy,腎臟的功能,調節水份 調節酸鹼 調節電解質 尿液的形成 內分泌器官 Vitamin D, erythropoietin,Outline,Renal function Acute renal failure Complication of ARF Management Renal replacement therapy,Definition,rapid (hours to weeks) decline in glomerular filtration rate and retention of waste products Lack a uniform definition Cr 1.5x, urine output .5ml/kg/hr Cr increase 1.0 mg/dl/2d Incidence 5% of hospital admission up to 30% of admission to intensive care units.,Prerenal azotemia,Intravascular volume depletion (hypovolemia) Major trauma, burns, crush syndrome, hemorrhage, dehydration GI fluid loss: vomiting, surgical drainage, diarrhea Renal fluid loss: diuretics, osmotic diuresis, adrenal insufficiency Sequestration of fluid in extravascular space: pancreatitis, peritonitis, hypoalbuminemia,Classification of Renal Failure,(1) Prerenal abnormality (Prerenal azotemia): disorder of renal hypoperfusion which intrinsically normal (2) Intrinsic renal abnormality (renal azotemia): disease of the renal parenchyma (3) Postrenal abnormality (postrenal azotemia): acute obstruction of urinary tract,Prerenal Azotemia,Decreased cardiac output (low cardiac output) Severe congestive heart failure or low cardiac output syndrome: myocardial failure, valvular or pericardial disease, including arrhythmias and tamponade Pulmonary hypertension, massive pulmonary embolism Positive pressure mechanical ventilation,Prerenal Azotemia,Increased renal /systemic vascular resistance ratio Systemic vasodilatation: sepsis, antihypertensive agents, afterload reducers, anesthesia, anaphylaxis Renal vasoconstriction: hypercalcemia, norepinephrine, epinephrine, cyclosporin, amphotericin B Liver cirrhosis with ascite,Prerenal Azotemia,Increased blood viscosity (hyperviscosity syndrome) Multiple myeloma, macroglobulinemia, polycythemia Renal hypoperfusion with impairment of renal autoregulatory responses Renal artery obstruction: artherosclerosis, embolism, thrombosis, dissecting aneurysm Cyclooxygenase inhibitors, angiotension-converting enzyme inhibitors,Intrinsic Azotemia,Acute tubular necrosis Ischemia: as for prerenal azotemia, obstetrical complication (abruptio plancentae, postpartum hemorrhage) Nephrotoxic damage: contrast media, antibiotics (e.g. aminoglycosides, amphotericin B), cyclosporine, chemotherapeutic agents( e.g. cisplatin), organic solvents (e.g. Ethylene glycol), heavy mental, snake venom, mushrooms, sulfonamide Pigment nephropathy: myoglobin, hemoglobin tumor-specific syndrome: plasma cell dyscrasia, tumor lysis,Intrinsic Azotemia,Disease of glomeruli or renal microvasculature Glomerulonephritis and vasculitis Hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, toxemia of pregnancy, accelerated hypertension, radiation nephritis, scleroderma, systemic lupus erythematosus,Intrinsic Azotemia,Interstitial nephritis Allergic: antibiotics (e.g. beta-lactams, sulfonamides, trimethoprime, rifampicin), Cyclooxygenase inhibitors, diuretics, captopril Infection: bacterial (e.g. acute pyelonephritis, leptospirosis), viral (e.g. CMV), fungal Infiltration: lymphoma, leukemia, sarcoidosis,投影片摘要,Intrinsic Azotemia,Intrinsic Azotemia,Renal vein obstruction: thrombosis, compression Intratubular deposition and obstruction myeloma proteins, uric acid, oxalate, acyclovir, methotrexate,Postrenal Causes of Renal Failure,Obstruction of ureters Extraureteral tumor: cervix, prostate, endometriosis Periureteral fibrosis (retroperitoneal fibrosis) accidental ureteral ligation during operation Intraureteral stone, blood clots, pyogenic debris, papillary necrosis Bladder neck obstruction Neurogenic bladder, bladder carcinoma, prostate hyperplasia, calculi Urethral obstruction Stricture, phimosis, congenital valve, tumor,Symptoms and Signs,Retention of nitrogenous waste products Nausea, vomiting, diarrhea, hiccup, foul taste, dry crusted mouth, itching, Drowsiness, clouding of consciousness, neuropathy, pericarditis, GI bleeding, Coma Retention of salt and water Pulmonary edema, peripheral edema, ascites, pleural effusion,Symptoms and Signs of Renal Failure,Retention of potassium Weakness, lassitude, paralysis, EKG changes with tenting T waves, widening of QRS complex, increased PR interval, sine wave pattern, cardiac arrest, VT Retention of acid Kussmaul respiration, hyperreflexia, hypotension,Edema Impairment of renal function,Outline,Renal function Acute renal failure Complication of ARF Management Renal replacement therapy,Cardiopulmonary complication Metabolic complication Gastrointestinal complication Neurogenic complication Hematological complication Infection,Complications of Renal Failure,Cardiopulmonary Complications,Cardiovascular Pulmonary edema Arrhythmia Hypertension Pericardial effusion Myocardial infarction Pulmonary embolism Congestive heart failure,Hypertension and Edema,Inability of the kidney to excrete sodium blood volume hypertension and edema,Metabolic Complications,Metabolic Acidosis Hyponatremia Hyperkalemia Hypocalcemia Hyperphosphatemia Hypermagnesemia Hypomagnesemia Hyperuricemia,Metabolic Acidosis,Inability of the kidney to secrete hydrogen ions and conserve bicarbonate,Hyperkalemia,K+ competes with H+ for Na+ exchange Tubular excretion of potassium Hyperkalemic acidosis Excretion of aldosterone Excretion of potassium in collecting duct Hyperkalemia,Gastrointestinal Complications,Gastrointestinal Nausea Vomiting Gastritis Gastroduodenal ulcer Gastrointestinal bleeding Malnutrition,Neurogenic Complications,Neurogenic Asterixis Neuromuscular irritability Mental status changes Somnolence Coma Seizure,Hematological Complications,Hematological Anemia Hemorrhagic bleeding Infection Pneumonia, septicemia Urinary tract infection, wound infection,Anemia,Erythropoietin decrease Erythropoietin: stimulates bone marrow to produce red blood cells. Toxic wastes suppress the ability of bone marrow to produce red blood cells.,Bleeding,Platelet abnormality Normal or a little decreased platelet number Platelet dysfunction Epistaxis, GI bleeding, bruising, hemoptysis,ARF VS ALI,Mortality ARF: 30-40% ALI: 35% BOTH: 80%,ARF VS ALI,Effect of ARF on lung ( Experimental studies) Increase pulmonary vascular permeability, macrophage medicated in part Salt and water transporters disorder: lung fluid retention,ARF VS ALI,Effect of mechanical ventilator on kidney ( Experimental studies) Systemic hemodynamic change( VR, CO ) Anti-natriuretic, anti-diuretic effect Augmentation of inflammatory milieu,Outline,Renal function Acute renal failure Complication of ARF Management Renal replacement therapy,Management,Prevention Etiology treatment Prevention additional injury Establish diuresis Treatment of complication Conservative measurement Renal replacement therapy,Prevention,Identification of high-risk patients for pharmacologic agents-induced nephrotoxicity iodinated radiocontrast medium, NSAIDs Aggressive surveillance for nephrotoxin-induced renal dysfunction cisplatin, amphotericin B, aminoglycoside Use of volume expansion in selected clinical settings Hyperpigmenturia: hemoglobinuria, myoglobinuria Crystaluria: uric acid, acyclovir, methotrexate, sulfonamides Minimalization of catheters use to avoid nosocomial sepsis,Etiology Treatment,Correct postrenal factor Correct prerenal factor Treat underlying sepsis Stop nephrotoxic drugs,Establish Diuresis,Volume expansion/hydration osmotic diuretics and loop diuretics: mannitol, furosemide renal vasodilators: dopamine (1-2ug/kg/min), atrial natriuretic peptid,Evaluation of intravascular volume,Guide of Volume Expansion,CVP 8-14 cm H2O (5-2 rule) PAWP 12-16 mmHg (7-3 rule) Urine output 0.5-1.0ml/kg/hour Weighing the patient daily Insensible water loss from the skin and respiratory tract (500 ml/day),Conservative Measurement,Fluid balance Careful monitoring of I/O and body weight Fluid restriction (usually less than 1 L/day in oliguric ARF) Total intake 15 hyperphosphatemia Treat hypocalcemia only if symptomatic,Dietary modification,total caloric intake 35 50 kcal/kg/day to avoid catabolism Salt restriction 24 g/day Potassium intake 40 meq/day Phosphorus intake 800 mg/day,Uremia-nutrition Restriction protein but maintain caloric intake Carbohydrate 100gm/day to minimize ketosis and protein catabolism Drug Review all medication, Stop magnesium-containing medication Adjusted dosage for renal failure, Readjust with improvement of GFR,Conservative Measurement,Outline,Renal function Acute renal failure Complication of ARF Management Renal replacement therapy,Indications for Renal Replacement Therapy,Prophylactic dialysis: BUN 80-100 mg/dl , creatinine 8-10 mg/dl Volume overloading with refractory to diuretics Pulmonary edema Hyperkalemia 6.5 mEq/l Severe metabolic acidosis 7.2,Indications for Renal Replacement Therapy,Uremic pericarditis Uremic encephalopathy: coma, seizure Acute uric acid nephropathy,Methods for Renal Replacement Therapy,Intermittent hemodialysis Peritoneal dialysis Continuous renal replacement therapy: CAVH/CAVHD/CVVHDF, CVVH/CVVHD/CVVHDF,Mechanisms,diffusion: movement of solute towards the same concentration on each side of membrane. convection: solute is carried together with solvent across the membrane by filtration. ultrafiltration: plasma water and crystalloids separated from the whole blood across a semipermeable membrane in response to a TMP. osmosis: operates in peritoneal dialysis. ( glucose is the osmotic agent ),HD,HF,HDF,HFD,Intermittent hemodialysis in ARF and critically ill patients,Peritoneal dialysis,infusion of pyogen-free solution into the peritoneal cavity, drained in subsequent cycles. Mechanism: diffusion, convection, and osmotic ultrafilation Modalities: intermittent peritoneal dialysis ( IPD ), continuous equilibrated peritoneal dialysis ( CPD ), tidal peritoneal dialysis ( TPD ). Indications: patients at risk of bleeding fluid overload in CV instability,Peritoneal dialysis,Continuous renal replacement therapy,種類： 連續性動脈靜脈血液過濾術(CAVH) 連續性靜脈靜脈血液過濾術（CVVH） 連續性動脈靜脈血液透析術（CAVHD） 連續性靜脈靜脈血液透析術（CVVHD） 連續性動脈靜脈血液透析過濾術（CAVHDF） 連續性靜脈靜脈血液透析過濾術（CVVHDF）,CAVH,CVVH,Comparison of different CRRT Modalities,急性腎衰竭仍是重症病患常見併發症之一，且死亡率極高( 50%) 重症病患常合併有低血壓，血行動力不穩，多重器官衰竭；且常需大量輸液 (升壓劑, 輸血) 合併急性腎衰竭需透析時常合併 (1) 血行動力不穩定 (2) 大量輸液無法依需要給予（如TPN) CRRT提供另類腎替代療法的選擇，並可避免傳統間歇性血液透析(intermittent hemodialysis, IHD)執行上的缺點,CRRT 操作原理,1.連續性治療 2.多種腎替代治療方式可供選擇 convective clearance (hemofiltration) diffusive clearance (hemodialysis) 合併上述兩項（HDF) 3.血管通路自主性 arteriovenous v.s. venovenous,CRRT的適應症,A. Renal indications -hemodynamic instability -multiple organs dysfunction syndrome accompanied by renal failure -acute renal failure with cerebral edema B. Non-Renal indications -possible removal of substances active as mediators,CRRT 的優點,avoidance of electrolyte, water and urea fluctuation gradual urea removal hemodynamic stability with slow ultrafiltration optimal fluid balance and unlimited alimentation elimination of septic mediators lower intracranial pressure improved outcome,CRRT的缺點,需動脈穿刺（如CAVHD) 出血危險性（常需使用抗凝劑） limited mobility slower solute and fluid removal 動脈壓力不穩定,理想的補充液 (replacement fluid),接近 plasma water approximate normal plasma water composition, replacing electrolytes an