【持续性肾脏替代治疗crrt英文精品课件】renalreplacementtherapyinpatientswithsepsisandacutekidneyinjury

RENAL REPLACEMENT THERAPY IN PATIENTS WITH SEPSIS AND ACUTE KIDNEY INJURY,Prof. Dr. Raymond Vanholder University Hospital Ghent Belgium,TIMING START RRT,ES: Early Start; BUN: Blood Urea Nitrogen; UO: urine output; + favors ES; 0 neutral *: early vs. late low vol (72L/d) no late comparator; *: UO 100 mL/d to start vs. other parameters (K, crea) irrespective of UO Gettings et al, Intens Care Med, 1999; Guerin et al, Am J Resp CCM, 2000; Bouman et al, CCM, 2002; Elahi et al, Eur J Cardio-thor Surg, 2004; Demirkili et al, J Card Surg, 2004; Liu et al, Clin JASN 2006 ; Piccinni et al, Intens Care Med 2006,C. Bouman, Crit Care Med, 30: 2205-2211; 2002,Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: A prospective, randomized trial Bouman, Catherine S. C. MD; Oudemans-van Straaten, Heleen M. MD, PhD; Tijssen, Jan G. P. MD, PhD; Zandstra, Durk F. MD, PhD; Kesecioglu, Jozef MD, PhD From the Departments of Intensive Care (CSCB) and Clinical Epidemiology (JGPT), Academic Medical Center, Amsterdam, The Netherlands; the Department of Anesthesiology, Cardiothoracic and Neurosurgical Intensive Care Unit, University Medical Center, Utrecht, The Netherlands (JK); and the Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (HMOvS, DFZ). Address requests for reprints to: Catherine S. C. Bouman, MD, Academic Medical Center, Department of Intensive Care, Meibergdreef 9, Amsterdam NL-1105 AZ, The Netherlands. E-mail: C.S.BoumanAMC.uva.nl,V. Seabra et al, AJKD, 52: 272-284; 2008,IMPACT ON MORTALITY,V. Seabra et al, AJKD, 52: 272-284; 2008,V. Seabra et al, AJKD, 52: 272-284; 2008,IMPACT ON RECOVERY RENAL FUNCTION,V. Seabra et al, AJKD, 52: 272-284; 2008,ABSTRACT Background Some studies have suggested that early institution of renal replacement therapy (RRT) might be associated with improved outcomes in patients with acute renal failure (ARF). Study Design A systematic review and meta-analysis of randomized controlled trials and cohort comparative studies to assess the effect of early RRT on mortality in patients with ARF. Setting however, early dialysis therapy was associated more strongly with lower mortality in smaller studies (n 100) by means of subgroup analysis. Limitations Paucity of randomized controlled trials, use of variable definitions of early RRT, and publication bias preclude definitive conclusions. Conclusion This hypothesis-generating meta-analysis suggests that early initiation of RRT in patients with ARF might be associated with improved survival, calling for an adequately powered randomized controlled trial to address this question.,Vinsonneau et al, Lancet, 368, 379-385, 2006,MOST RECENT STUDIES,Vinsonneau et al, Lancet, 368, 379-385, 2006,R. L. Lins et al, NDT, advance access published October 14, 2008,R. L. Lins et al, NDT, advance access published October 14, 2008,THE SHARF STUDY,Bagshaw et al, Crit Care Med, 36: 610-617; 2008,Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis Bagshaw, Sean M. MD, MSc; Berthiaume, Luc R. MD; Delaney, Anthony MBBS, MSc; Bellomo, Rinaldo MD From the Division of Critical Care Medicine, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada (SMB); Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia (SMB, RB); Departments of Critical Care Medicine and Community Health Sciences, Calgary Health Region and University of Calgary, Calgary, Alberta, Canada (LRB); and Intensive Care Unit, Royal North Shore Hospital, and Northern Clinical School, University of Sydney, Sydney, NSW, Australia (AD).,W. Van Biesen et al, Crit Care Med, 36: 649-650; 2008,A tantalizing question: Ferrari or Rolls Royce? A meta-analysis on the ideal renal replacement modality for acute kidney injury at the intensive care unit Van Biesen, Wim MD, PhD; Lameire, Norbert MD, PhD; Vanholder, Raymond MD, PhD Renal Division; Department of Internal Medicine; University Hospital Ghent; Ghent, Belgium,FACTORS AFFECTING CHOICE,Labor intensity Cost Availability of machines Availability of SLEDD as alternative,Extended Daily Dialysis: what?,Offering the choice between the advantages of a IHDF-monitor (high efficiency, low cost, high precision of UF control) in combination with the advantages of CRRT (extended treatment, smooth metabolic control) in a modular fashion, using one single type of dialysis machine Dialysis monitor with: Water treatment module Reverse osmosis unit Hemofiltration capacity Dialysate flow adjustment,TOTAL NUMBER, DURATION, AND MEDIAN NUMBER OF TREATMENTS PERFORMED,Kumar et al. Am J Kidney Dis 36:294-300,2000,Comparison of MAP during EDD vs. CVVH.,Kumar et al, AJKD, 36, 294-300, 2000,P=NS,P=NS,P=NS,Percentage of treatment days requiring inotropic support,% of treatment days,Kumar et al, AJKD, 36, 294-300, 2000,Single Pass Batch Hemodialysis System (GENIUS): preparation of dialysis water and dialysate,Cumulative ultrafiltration volume and mean arterial pressure during 18h of extended high-flux HD using the Genius System,Lonnemann et al, NDT, 15, 1189-1193, 2000,R. Busund et al, Int Care Med, 28: 1434-1439; 2002,PF: signif younger & less mechanical ventilation,J. Tumlin et al, JASN, 19: 1034-1040; 2008,Schiffl et al, NEJM, 346: 305-310; 2002,P. Honore et al, Crit Care Med, 28: 3581-3587; 2000,Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock Honore, Patrick, Jamez, Jean, Wauthier, Michel, Lee, Patrice, Dugernier, Thierry, Pirenne, Bruno, Hanique, Genevieve, Matson, James From the Departments of Intensive Care Medicine (Drs. Honore, Dugernier, and Pirenne) and Nephrology (Drs. Jamez and Wauthier), St-Pierre Hospital, Ottignies, Belgium; the Department of Clinical Research and Pediatric Critical Care (Drs. Lee and Matson), Dallas Hospital, Dallas, TX; and the Department of Internal Medicine and Biostatistics (Dr. Hanique), Nivelles Hospital, Nivelles, Belgium,C. Ronco et al, The Lancet, 256: 26-30; 2000,P. Saudan et al, KI, 70: 1312-1317; 70,C. Bouman, Crit Care Med, 30: 2205-2211; 2002,Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: A prospective, randomized trial Bouman, Catherine S. C. MD; Oudemans-van Straaten, Heleen M. MD, PhD; Tijssen, Jan G. P. MD, PhD; Zandstra, Durk F. MD, PhD; Kesecioglu, Jozef MD, PhD From the Departments of Intensive Care (CSCB) and Clinical Epidemiology (JGPT), Academic Medical Center, Amsterdam, The Netherlands; the Department of Anesthesiology, Cardiothoracic and Neurosurgical Intensive Care Unit, University Medical Center, Utrecht, The Netherlands (JK); and the Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (HMOvS, DFZ). Address requests for reprints to: Catherine S. C. Bouman, MD, Academic Medical Center, Department of Intensive Care, Meibergdreef 9, Amsterdam NL-1105 AZ, The Netherlands. E-mail: C.S.BoumanAMC.uva.nl,Palevsky et al, NEJM, 359, 1: 7-20; 2008,Intensive vs less intensive therapy Intermittent hemodialysis (hemodynamically stable) Intensive: daily except Sunday Less intensive: alternate days except Sunday Sustained low-efficiency dialysis (hemodynamically unstable) Intensive: daily except Sunday Less intensive: alternate days except Sunday Continuous renal replacement therapy (hemodynamically unstable) Intensive: 35 mL/h/kgBW substitution Less intensive: 20 mL/h/kgBW substitution,Palevsky et al, NEJM, 359, 1: 7-20; 2008,KAPLANMEIER PLOT OF CUMULATIVE PROBABILITIES OF DEATH CUMULATIVE PROBABILITY OF DEATH FROM ANY CAUSE IN THE ENTIRE STUDY COHORT,COMMENTS,Standard IHD more efficient than in Schiffl et al Hemodiafiltration Shifts among therapies possible Kt/V not a validated parameter of adequacy in AKI More adequate treatment may also have negative impact REAL-LIFE STUDIES,Single Pass Batch Hemodialysis System (GENIUS): preparation of dialysis water and dialysate,GENIUSR,S. Eloot et al, NDT, 22: 2962-2969; 2007,Eloot et al, KI, 73: 765-770,RESULTS: TOTAL SOLUTE REMOVAL TSR,PERCENTAGE CHANGE VS. 4 HRS,Eloot et al, KI, 73: 765-770,COMMENTS,Standard IHD more efficient than in Schiffl et al Hemodiafiltration Shifts among therapies possible Kt/V not a val