KDIGO-AKI急性肾损伤诊疗指南解读2012版.ppt

KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury 2012 东阿县人民医院 于立杰 KDIGO KidneyDiseaseImprovingGlobalOutcomes AboutAKIguideline ADQI 2002 RIFLEAKIN 2005 modifieddefinitionandstagingsystemKDIGO 2011 FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI 2011UKRenalAssociationFinalVersion08 03 11AKIguidline KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury 指南推荐强度 指南推荐强度 AKIisde nedasanyofthefollowing NotGraded IncreaseinSCrby0 3mg dl X26 5mol l within48hours orIncreaseinSCrto1 5timesbaseline whichisknownorpresumedtohaveoccurredwithintheprior7days orUrinevolume0 5ml kg hfor6hours 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 Guideline Chapter2 2 Riskassessment Chapter2 2 Riskassessment OverviewofAKI CKD andAKD OverlappingovalsshowtherelationshipsamongAKI AKD andCKD AKIisasubsetofAKD BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD IndividualswithoutAKI AKD orCKDhavenoknownkidneydisease NKD notshownhere AKD acutekidneydiseasesanddisorders AKI acutekidneyinjury CKD chronickidneydisease AKI CKD AKD Guideline3 PreventionandTreatmentofAKI HIGHRISK Stage basedmanagementofAKI Chapter2 3 EvaluationandgeneralmanagementofpatientswithandatriskforAKI Guidline3 Intheabsenceofhemorrhagicshock wesuggestusingisotoniccrystalloidsratherthancolloids albuminorstarches asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI 2B Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith oratriskforAKI 1C Wesuggestusingprotocol basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh riskpatientsintheperioperativesetting 2C orinpatientswithsepticshock 2C Diuretics against MehtaRL PascualMT SorokoSetal Diuretics mortality andnonrecoveryofrenalfunctioninacuterenalfailure JAMA2002 288 2547 2553HoKM SheridanDJ Meta analysisoffrusemidetopreventortreatacuterenalfailure BMJ2006 333 7565 420 425 Chapter3 4 TheuseofdiureticsinAKI WerecommendnotusingdiureticstopreventAKI 1B WesuggestnotusingdiureticstotreatAKI exceptinthemanagementofvolumeoverload 2C TheuseofdiureticsinAKI Atpresent thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI MannitolisnotscientificallyjustifiedinthepreventionofAKI Vasodilatortherapy dopamine fenoldopam andnatriureticpeptides Werecommendnotusinglow dosedopaminetopreventortreatAKI 1A Wesuggestnotusingfenoldopam 非诺多巴 topreventortreatAKI 2C Wesuggestnotusingatrialnatriureticpeptide ANP toprevent 2C ortreat 2B AKI Glycemiccontrolandnutritionalsupport Incriticallyillpatients wesuggestinsulintherapytargetingplasmaglucose110 149mg dl 6 1 8 3mmol l 2C Wesuggestachievingatotalenergyintakeof20 30kcal kg dinpatientswithanystageofAKI 2C WesuggesttoavoidrestrictionofproteinintakewiththeaimofpreventingordelayinginitiationofRRT 2D Wesuggestadministering0 8 1 0g kg dofproteininnoncatabolicAKIpatientswithoutneedfordialysis 2D 1 0 1 5g kg dinpatientswithAKIonRRT 2D anduptoamaximumof1 7g kg dinpatientsoncontinuousrenalreplacementtherapy CRRT andinhypercatabolicpatients 2D WesuggestprovidingnutritionpreferentiallyviatheenteralrouteinpatientswithAKI 2C Growthfactorintervention Werecommendnotusingrecombinanthuman rh IGF 1topreventortreatAKI 1B humanIGF 1 重组人胰岛素样生长因子1 Preventionofaminoglycoside andamphotericin relatedAKI Wesuggestnotusingaminoglycosidesforthetreat mentofinfectionsunlessnosuitable lessnephro toxic therapeuticalternativesareavailable 2A Wesuggestthat inpatientswithnormalkidneyfunctioninsteadystate aminoglycosidesareadministeredasasingledosedailyratherthanmultiple dosedailytreatmentregimens 2B Werecommendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours 1A Wesuggestmonitoringaminoglycosidedruglevelswhentreatmentwithsingle dailydosingisusedformorethan48hours 2C Wesuggestusingtopicalorlocalapplicationsofaminoglycosides e g respiratoryaerosols instilledantibioticbeads ratherthani v application whenfeasibleandsuitable 2B Preventionofaminoglycoside andamphotericin relatedAKI Wesuggestusinglipidformulationsofampho tericinBratherthanconventionalformulationsofamphotericinB 2A Inthetreatmentofsystemicmycosesorparasiticinfections werecommendusingazoleantifungalagentsand ortheechinocandinsratherthanconventionalamphotericinB ifequaltherapeuticefficacycanbeassumed 1A Guidline Wesuggestthatoff pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT 2C WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension 2D Werecommendnotusingoralori v NACforpreventionofpostsurgicalAKI 1A Guidline InitiateRRTemergentlywhenlife threateningchangesin uid electrolyte andacid basebalanceexist NotGraded Considerthebroaderclinicalcontext thepresenceofconditionsthatcanbemodi edwithRRT andtrendsoflaboratorytests ratherthansingleBUNandcreatininethresholdsalone whenmakingthedecisiontostartRRT NotGraded Guidline WhenchoosingaveinforinsertionofadialysiscatheterinpatientswithAKI considerthesepreferences NotGraded Firstchoice rightjugularvein Secondchoice fem