KDIGO急性肾损伤指南解读PPT课件.ppt

KDIGO急性肾损伤指南解读 1 KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury Kidneyinter Suppl 2012 2 1 138 2 GRADE系统 3 总推荐条目87条 未分级26条29 9 2级39条63 9 1级22条36 1 1A 914 8 1B 1016 4 1C 34 9 2A 23 3 2B 1016 4 2C 2032 8 2D 711 5 4 内容 IntroductionandMethodologyAKIDefinitionPreventionandTreatmentofAKIContrast inducedAKIDialysisInterventionsforTreatmentofAKI 5 符合下列任何一条即可诊断1 IncreaseinSCrby 0 3mg dl 26 5lmol l within48hours2 IncreaseinSCrto 1 5timesbaseline whichisknownorpresumedtohaveoccurredwithintheprior7days3 Urinevolume 0 5ml kg hfor6hours AKI诊断 NotGraded 6 StageSerumcreatinineUrineoutput11 5 1 9timesbaselineOR 0 5ml kg hfor 0 3mg dl 26 5mmol l increase6 12hours22 0 2 9timesbaseline 0 5ml kg hfor 12hours33 0timesbaselineORIncreaseinserumcreatinineto 0 3ml kg hfor 4 0mg dl 353 6mmol l 24hoursORORInitiationofrenalreplacementtherapyAnuriafor 12hoursOR Inpatients 18years decreaseineGFRto 35ml minper1 73m2 AKI分级 NotGraded 7 ThecauseofAKIshouldbedeterminedwheneverpossible NotGraded SelectedcausesofAKIrequiringimmediatediagnosisandspecifictherapiesRecommendeddiagnostictestsDecreasedkidneyperfusionVolumestatusandurinarydiagnosticindicesAcuteglomerulonephritis vasculitis Urinesedimentexamination interstitialnephritis thromboticserologictestingandMicroangiopathyhematologictestingUrinarytractobstructionKidneyultrasound 8 WerecommendthatpatientsbestratifiedforriskofAKIaccordingtotheirsusceptibilitiesandexposures 1B ManagepatientsaccordingtotheirsusceptibilitiesandexposurestoreducetheriskofAKI NotGraded TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI NotGraded Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse NotGraded 9 ExposuresSusceptibilitiesSepsisDehydrationorvolumedepletionCriticalillnessAdvancedageCirculatoryshockFemalegenderBurnsBlackraceTraumaCKDCardiacsurgery especiallyChronicdiseases heart lung liver withCPB MajornoncardiacsurgeryDiabetesmellitusNephrotoxicdrugsCancerRadiocontrastagentsAnemiaPoisonousplantsandanimals CausesofAKI exposuresandsusceptibilitiesfornon specificAKI 10 EvaluatepatientswithAKIpromptlytodeterminethecause withspecialattentiontoreversiblecauses NotGraded MonitorpatientswithAKIwithmeasurementsofSCrandurineoutputtostagetheseverity accordingtoRecommendation NotGraded ManagepatientswithAKIaccordingtothestageandcause NotGraded 11 12 13 AKI时RRT治疗时机 InitiateRRTemergentlywhenlife threateningchangesinfluid electrolyte andacid basebalanceexist NotGraded Considerthebroaderclinicalcontext thepresenceofconditionsthatcanbemodifiedwithRRT andtrendsoflaboratorytests ratherthansingleBUNandcreatininethresholdsalone whenmakingthedecisiontostartRRT NotGraded 14 PotentialapplicationsforRRT ApplicationsCommentsRenalreplacementThisisthetraditional prevailingapproachbasedonutilizationofRRTwhenthereislittleornoresidualkidneyfunction Life threateningindicationsNotrialstovalidatethesecriteria HyperkalemiaDialysisforhyperkalemiaiseffectiveinremovingpotassium however itrequiresfrequentmonitoringofpotassiumlevelsandadjustmentofconcurrentmedicalmanagementtopreventrelapses AcidemiaMetabolicacidosisduetoAKIisoftenaggravatedbytheunderlyingcondition CorrectionofmetabolicacidosiswithRRTintheseconditionsdependsontheunderlyingdiseaseprocess PulmonaryedemaRRTisoftenutilizedtopreventtheneedforventilatorysupport however itisequallyimportanttomanagepulmonaryedemainventilatedpatients Uremiccomplications pericarditis bleeding etc IncontemporarypracticeitisraretowaittoinitiateRRTinAKIpatientsuntilthereareuremiccomplications 15 PotentialapplicationsforRRT ApplicationsCommentsNonemergentindicationsSolutecontrolBUNreflectsfactorsnotdirectlyassociatedwithkidneyfunction suchascatabolicrateandvolumestatus SCrisinfluencedbyage race musclemass andcatabolicrate andbychangesinitsvolumeofdistributionduetofluidadministrationorwithdrawal FluidremovalFluidoverloadisanimportantdeterminantofthetimingofRRTinitiation Correctionofacid baseAbnormalitiesNostandardcriteriaforinitiatingdialysisexist 16 PotentialapplicationsforRRT ApplicationsCommentsRenalsupportThisapproachisbasedontheutilizationofRRTtechniquesasanadjuncttoenhancekidneyfunction modifyfluidbalance andcontrolsolutelevels VolumecontrolFluidoverloadisemergingasanimportantfactorassociatedwith andpossiblycontributingto adverseoutcomesinAKI RecentstudieshaveshownpotentialbenefitsfromextracorporealfluidremovalinCHF Intraoperativefluidremovalusingmodifiedultrafiltrationhasbeenshowntoimproveoutcomesinpediatriccardiacsurgerypatients NutritionRestrictingvolumeadministrationinthesettingofoliguricAKImayresultinlimitednutritionalsupportandRRTallowsbetternutritionalsupplementation DrugdeliveryRRTsupportcanenhancestheabilitytoadministerdrugswithoutconcernsaboutconcurrentfluidaccumulation RegulationofPermissivehypercapnicacidosisinpatientswithlunginjurycanbecorrectedacid basewithRRT withoutinducingfluidoverloadandhypernatremia andelectrolytestatusSoluteChangesinsoluteburdenshouldbeanticipated e g tumorlysismodulationsyndrome Althoughcurrentevidenceisunclear studiesareongoingtoassesstheefficacyofRRTforcytokinemanipulationinsepsis 17 AKI时停用RRT指征 DiscontinueRRTwhenitisnolongerrequired eitherbecauseintrinsickidneyfunctionhasrecoveredtothepointthatitisadequatetomeetpatientneeds orbecauseRRTisnolongerconsistentwiththegoalsofcare NotGraded Wesuggestnotusingdiureticstoenhancekidneyfunctionrecovery ortoreducethedurationorfrequencyofRRT 2B 18 抗凝治疗 InapatientwithAKIrequiringRRT basethedecisiontouseanticoagulationforRRTonassessmentofthepatient spotentialrisksandbenefitsfromanticoagulation NotGraded WerecommendusinganticoagulationduringRRTinAKIifapatientdoesnothaveanincreasedbleedingriskorimpairedcoagulationandisnotalreadyreceivingsystemicanticoagulation 1B 19 Forpatientswithoutanincreasedbleedingriskorimpairedcoagulationandnotalreadyreceivingeffectivesystemicanticoagulation wesuggestthefollowing ForanticoagulationinintermittentRRT werecommendusingeitherunfractionatedorlow molecular weightheparin ratherthanotheranticoagulants 1C ForanticoagulationinCRRT wesuggestusingregionalcitrateanticoagulationratherthanheparininpatientswhodonothavecontraindicationsforcitrate 2B ForanticoagulationduringCRRTinpatientswhohavecontraindicationsforcitrate wesuggestusingeitherunfractionatedorlow molecular weightheparin ratherthanotheranticoagulants 2C 抗凝治疗 20 Forpatientswithincreasedbleedingriskwhoarenotreceivinganticoagulation wesuggestthefollowingforanticoagulationduringRRT Wesuggestusingregionalcitrateanticoagulation ratherthannoanticoagulation duringCRRTinapatientwithoutcontraindicationsforcitrate 2C WesuggestavoidingregionalheparinizationduringCRRTinapatientwithincreasedriskofbleeding 2C 抗凝治疗 21 Inapatientwithheparin inducedthrombocytopenia HIT allheparinmustbestoppedandwerecommendusingdirectthrombininhibitors suchasargatroban orFactorXainhibitors suchasdanaparoidorfondaparinux ratherthanotherornoanticoagulationduringRRT 1A InapatientwithHITwhodoesnothavesevereliverfailure wesuggestusingargatrobanratherthanotherthrombinorFactorXainhibitorsduringRRT 2C 抗凝治疗 22 23 血管通路 WesuggestinitiatingRRTinpatientswithAKIviaanuncuffednontunneleddialysiscatheter ratherthanatunneledcatheter 2D WhenchoosingaveinforinsertionofadialysiscatheterinpatientswithAKI considerthesepreferences NotGraded Firstchoice rightjugularvein Secondchoice femoralvein Thirdchoice leftjugularvein Lastchoice subclavianveinwithpreferenceforthedominantside 24 Werecommendusingultrasoundguidancefordialysiscatheterinsertion 1A Werecommendobtainingachestradiographpromptlyafterplacementandbeforefirstuseofaninternaljugularorsubclaviandialysiscatheter 1B WesuggestnotusingtopicalantibioticsovertheskininsertionsiteofanontunneleddialysiscatheterinICUpatientswithAKIrequiringRRT 2C Wesuggestnotusingantibioticlocksforpreventionofcatheter relatedinfectionsofnontunneleddialysiscathetersinAKIrequiringRRT 2C 血管通路 25 滤器选择 WesuggesttousedialyzerswithabiocompatiblemembraneforIHDandCRRTinpatientswithAKI 2C 26 RRT模式选择 UsecontinuousandintermittentRRTascomplementarytherapiesinAKIpatients NotGraded WesuggestusingCRRT ratherthanstandardintermittentRRT forhemodynamicallyunstablepatients 2B WesuggestusingCRRT ratherthanintermittentRRT forAKIpatientswithacutebraininjuryorothercausesofincreasedintracranialpressureorgeneralizedbrainedema 2B 27 TypicalsettingofdifferentRRTmodalitiesforAKI for70 kgpatient 28 TheoreticaladvantagesanddisadvantagesofCRRT IHD SLED andPD 29 缓冲液的选择 Wesuggestusingbicarbonate ratherthanlactate asabufferindialysateandreplacementfluidforRRTinpatientswithAKI 2C Werecommendusingbicarbonate ratherthanlactate asabufferindialysateandreplacementfluidforRRTinpatientswithAKIandcircul