CRRT开始时机zh8-7.ppt

肾脏替代治疗应何时开始？,KDIGO急性肾损伤（AKI）定义,符合下列情形之一 在48h内血清肌酐（SCr）上升0.3mg/dl（ 26.5umol/l）； 已知或假定肾损害发生在7d之内， （SCr）上升基础值的1.5倍； 尿量0.5ml/(kg.h)，持续6h。,KDIGO急性肾损伤（AKI）分期,KDIGO关于AKI开始RRT治疗时机意见,存在危及生命的水、电解质及酸碱平衡紊乱时应紧急启动RRT。 决定是否开始RRT，应全面考虑患者的临床背景，是否存在能被RRT改善的 病情，综合实验室检测结果的变化趋势，而非仅观察尿素氮和肌酐水平。,RRT的时机？,早期 “早期”策略的定义比教模糊，现用标准不统一。 生化标准：如血尿素氮（BUN）和血清肌酐（SCr） 。 依据AKI发生的时间或AKI的临床分期：例如使用危险、损伤、衰竭、肾功 能丧失、终末期肾病（RIFLE）或急性肾损伤工作组（AKIN）标准。 晚期 “晚期”即所谓的RRT“延迟”启动，经常被定义为存在“危及生命的指征” 时，也被称为“绝对适应症”或“经典适应症”。改善全球肾脏病预后（KDIGO）实践指南，提出危及生命的指征如下：高钾血症、酸中毒、肺水肿和尿毒症并发症。,AKIKI试验,Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. Gaudry S1, Hajage D1, Schortgen F1, Martin-Lefevre L1, Pons B1, Boulet E1, Boyer A1, Chevrel G1, Lerolle N1, Carpentier D1, de Prost N1, Lautrette A1,Bretagnol A1, Mayaux J1, Nseir S1, Megarbane B1, Thirion M1, Forel JM1, Maizel J1, Yonis H1, Markowicz P1, Thiery G1, Tubach F1, Ricard JD1, Dreyfuss D1; AKIKI Study Group. Collaborators (32) Author information Abstract BACKGROUND: The timing of renal-replacement therapy in critically ill patients who have acute kidney injury but no potentially life-threatening complication directly related to renal failure is a subject of debate. METHODS: In this multicenter randomized trial, we assigned patients with severe acute kidney injury (Kidney Disease: Improving Global Outcomes KDIGO classification, stage 3 stages range from 1 to 3, with higher stages indicating more severe kidney injury) who required mechanical ventilation, catecholamine infusion, or both and did not have a potentially life-threatening complication directly related to renal failure to either an early or a delayed strategy of renal-replacement therapy. With the early strategy, renal-replacement therapy was started immediately after randomization. With the delayed strategy, renal-replacement therapy was initiated if at least one of the following criteria was met: severe hyperkalemia, metabolic acidosis, pulmonary edema, blood urea nitrogen level higher than 112 mg per deciliter, or oliguria for more than 72 hours after randomization. The primary outcome was overall survival at day 60. RESULTS: A total of 620 patients underwent randomization. The Kaplan-Meier estimates of mortality at day 60 did not differ significantly between the early and delayed strategies; 150 deaths occurred among 311 patients in the early-strategy group (48.5%; 95% confidence interval CI, 42.6 to 53.8), and 153 deaths occurred among 308 patients in the delayed-strategy group (49.7%, 95% CI, 43.8 to 55.0; P=0.79). A total of 151 patients (49%) in the delayed-strategy group did not receive renal-replacement therapy. The rate of catheter-related bloodstream infections was higher in the early-strategy group than in the delayed-strategy group (10% vs. 5%, P=0.03). Diuresis, a marker of improved kidney function, occurred earlier in the delayed-strategy group (P0.001). CONCLUSIONS: In a trial involving critically ill patients with severe acute kidney injury, we found no significant difference with regard to mortality between an early and a delayed strategy for the initiation of renal-replacement therapy. A delayed strategy averted the need for renal-replacement therapy in an appreciable number of patients.,N Engl J Med. 2016 Jul 14;375(2):122-33.,AKIKI试验,BACKGROUND: 避免急性肾损伤重症患者发生与肾衰竭直接相关潜在威胁生命并发症的肾脏替代治疗时机一直是一个有争论的话题。,AKIKI试验,METHODS: 急性肾损伤启动人工肾治疗（AKIKI）研究于2013年9月至2016年1月在法国31个ICU进行。在这项多中心随机对照研究中，共纳入620例严重AKI（KDIGO 3期）患者，入选患者接受机械通气和（或）血管活性药物（肾上腺素或去甲肾上腺素）治疗。主要的排除标准为入院即存在需要进行透析的危及生命的指征：严重的高钾血症、代谢性酸中毒、肺水肿或BUN112mg/dl。患者被随机分至“RRT早期治疗组”或“RRT晚期治疗组”，619例患者进行了分析。早期治疗组，纳入后立即进行RRT治疗。晚期治疗组，如果出现上述排除标准中的异常情况之一或少尿72小时，才启动RRT治疗。主要观察指标为60天生存率。,AKIKI试验,RESULTS: 就60天的整体生存率而言，观察两组无显著差异，主要结果为：早期治疗组60天死亡率为48.5%（150/311），晚期治疗组为49.7%（153/308）。重要的是，晚期治疗组49%（151/311）的患者未接受RRT治疗。仅分析那些接受RRT治疗的患者，早期治疗组60天死亡率为48.5%，晚期治疗组为61.8%。那些从未接受RRT治疗的患者死亡率最低（37.1%），其基线值与其他组相比，序贯器官衰竭评分（SOFA）显示（P0.0001），其病情严重程度较低。另外，早期治疗组更易出现导管相关性血流感染（10%31/311 VS. 5%16/308，P=0.03）和低磷血症（22%69/311 VS.15%46/308，P=0.03）。以尿量为标志，晚期治疗组患者肾功能恢复可能比早期治疗组更早（P0.001）。,AKIKI试验,CONCLUSIONS: 在这项涉及严重急性肾脏损伤的危重病人的试验中，我们发现在早期治疗策略和延迟治疗策略之间的死亡率没有显著差异。延迟治疗策略避免了在相当数量的患者进行肾脏替代治疗。,ELAIN试验,Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial. Zarbock A1, Kellum JA2, Schmidt C1, Van Aken H1, Wempe C1, Pavenstdt H3, Boanta A1, Ger J4, Meersch M1. Author information Abstract IMPORTANCE: Optimal timing of initiation of renal replacement therapy (RRT) for severe acute kidney injury (AKI) but without life-threatening indications is still unknown. OBJECTIVE: To determine whether early initiation of RRT in patients who are critically ill with AKI reduces 90-day all-cause mortality. DESIGN, SETTING, AND PARTICIPANTS: Single-center randomized clinical trial of 231 critically ill patients with AKI Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 (2 times baseline or urinary output 0.5 mL/kg/h for 12 hours) and plasma neutrophil gelatinase-associated lipocalin level higher than 150 ng/mL enrolled between August 2013 and June 2015 from a university hospital in Germany. INTERVENTIONS: Early (within 8 hours of diagnosis of KDIGO stage 2; n = 112) or delayed (within 12 hours of stage 3 AKI or no initiation; n = 119) initiation of RRT. MAIN OUTCOMES AND MEASURES: The primary end point was mortality at 90 days after randomization. Secondary end points included 28- and 60-day mortality, clinical evidence of organ dysfunction, recovery of renal function, requirement of RRT after day 90, duration of renal support, and intensive care unit (ICU) and hospital length of stay.,JAMA. 2016 May 24-31;315(20):2190-9.,ELAIN试验,RESULTS: Among 231 patients (mean age, 67 years; men, 146 63.2%), all patients in the early group (n = 112) and 108 of 119 patients (90.8%) in the delayed group received RRT. All patients completed follow-up at 90 days. Median time (Q1, Q3) from meeting full eligibility criteria to RRT initiation was significantly shorter in the early group (6.0 hours Q1, Q3: 4.0, 7.0) than in the delayed group (25.5 h Q1, Q3: 18.8, 40.3; difference, -21.0 95% CI, -24.0 to -18.0; P 90 in the delayed group; P = .04; HR, 0.69 95% CI, 0.48 to 1.00; difference, -18 days 95% CI, -41 to 4; hospital stay: 51 days Q1, Q3: 31, 74 in the early group vs 82 days Q1, Q3: 67, 90 in the delayed group; P .001; HR, 0.34 95% CI, 0.22 to 0.52; difference, -37 days 95% CI, - to -19.5), but there was no significant effect on requirement of RRT after day 90, organ dysfunction, and length of ICU stay. CONCLUSIONS AND RELEVANCE: Among critically ill patients with AKI, early RRT compared with delayed initiation of RRT reduced mortality over the first 90 days. Further multicenter trials of this intervention are warranted.,JAMA. 2016 May 24-31;315(20):2190-9.,ELAIN试验,IMPORTANCE: 严重急性肾脏损伤(AKI)但尚未出现威胁生命时启动肾脏替代治疗(RRT)治疗的最佳时机仍然不清楚。 OBJECTIVE: 确定在合并AKI的危重症患者中，早期RRT治疗是否能减少90天的全因死亡率。,ELAIN试验,DESIGN, SETTING, AND PARTICIPANTS: 2013年8月至2015年7月于德国进行的单中心研究。共入选231名合并AKI的危重症患者。入选标准为KDIGO 2期且血浆中性粒细胞明胶酶相关脂质运载蛋白（NGAL）150 ng/ml。此外至少符合下列一项：严重脓毒症、大剂量的儿茶酚胺类药物、液体过负荷、或非肾脏SOFA评分2。 INTERVENTIONS: 早期组（诊断KDIGO2期8小时内启动RRT治疗，n=112），延迟组（诊断KDIGO3期或符合任意一项绝对适应证BUN100mg/dl，重度高钾血症（K6mEq/l），重度高镁血症（Mg8 mEq/l），尿量200ml/12h，器官水肿对袢利尿剂抵抗12小时后启动RRT治疗，n=119）,ELAIN试验,MAIN OUTCOMES AND MEASURES: 最主要的终点是在入组后90天的死亡率。次要终点包括28-60天死亡率，器官功能障碍，肾功能恢复，90天后RRT的需求，肾功能支持的持续时间以及住ICU时间和住院时间。,ELAIN试验,RESULTS: 在231名患者中(平均年龄，67岁；男性，146（63.2%）)，所有早期组患者(n=112)和晚期组90.8%的患者(108/119）接受了RRT治疗。所有患者在90天内完成随访。从符合标准入组到RRT开始的平均时间早期组(6.0 h)比延迟组(25.5 h)要短得多，P 0.001。与晚期组比较，早期组可显著降低其90天死亡率（39.3%44/112 VS. 54.7%65/119，P=0.03）。与晚期组比较，更多的早期组患者在90天内恢复了肾功能（53.6%60/112 VS.38.7%46/119，P=0.02）。在早期组中，RRT的持续时间和住院时间的明显短于延迟组(RRT:9天VS 25天; 住院时间: 51天VS 82天，P .001。） 但是在90天之后，RRT的需求，器官功能障碍，以及住ICU时间两组间无显著差异。,EL