KDIGOAKI诊疗指南解读

急性肾损伤诊疗指南解读,KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012,赵良斌,KDIGO：Kidney Disease Improving Global Outcomes,2012-KDIGO指南解读,急性肾损伤(AKI)与急性肾衰竭(ARF),国际肾脏病和急救医学界将ARF 改为急性肾损伤（Acute Kidney Injury, AKI）。AKI 覆盖的肾损伤,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006Biesen WV et al. CJASN. 2006,About AKI guideline,ADQI：2002, RIFLEAKIN：2005, modified definition and staging systemKDIGO: 2011, First clinical guideline for AKIWaiting for published in this summerAKI guideline for AKI :2011UK Renal Association Final Version 08.03.11AKI guidlineKDIGO 2012KDIGO Clinical Practice Guideline for Acute Kidney Injury,AKI流行病学现状,患病率：1%（社区） 7.1%（医院）人群发病率：486630 pmp/yAKI需要RRT发病率：22203pmp/y医院获得AKI死亡率：1080%合并多脏器功能衰竭死亡率：50%需要RRT治疗者死亡率：高达80%,指南推荐强度,指南推荐强度,Guideline 1：AKI的定义与分期,符合以下情况之一者即可被诊断为AKI：48小时内Scr升高超过26.5mol/L(0.3mg/dl)；Scr升高超过基线1.5倍确认或推测7天内发生；尿量0.5ml/（kgh），且持续6小时以上。单用尿量改变作为判断标准时，需要除外尿路梗阻及其它导致尿量减少的原因,采用KDIGO推荐的定义和分期标准,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),RIFLE分级,2002 年急性透析质量倡议组(ADQI)制定了ARF的 RIFLE 分级诊断标准。,Bellomo R, et al. Crit Care 2004;8:R204-R212,Conceptual model for AKI,Guideline 2：临床评估,2.1 详细的病史采集和体格检查有助于AKI病因的判断(1A)2.2 24小时之内进行基本的检查，包括尿液分析和泌尿系超声(怀疑有尿路梗阻者)(1A),Chapter 2.2: Risk assessment,Chapter 2.2: Risk assessment,AKI is defined as any of the following (Not Graded ): AKI is defined as any of the following (Not Graded ): KIncrease in SCr by X 0.3 mg/dl ( X26.5 lmol/l)within 48 hours; or KIncrease in SCr to X1.5 times baseline, whichis known or presumed to have occurred withinthe prior 7 days; orKUrine volume o0.5 ml/kg/h for 6 hours.Test patients at increased risk for AKI with measurements of SCr and urine output to detect AKI. ( Not Graded )Individualize frequency and duration of monitoring based on patient risk and clinical course. ( Not Graded ) Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes.(Not Graded ) he cause of AKI should be determined whenever possible. (Not Graded),Definition and staging of AKI,Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.,AKDacute kidney diseases and disorder,符合以下任何一项AKI, 符合AKI定义3个月内在原来基础上，GFR下降35%或Scr上升50%GFR60ml/min/1.73m2, 3个月肾损伤75岁CKD (eGFR3周：建议用皮下隧道导管导管仅限于RRT治疗时使用(1D)以预防感染,Guideline 9：体外抗凝,根据患者病情和RRT模式制定抗凝治疗方案(1C)推荐枸橼酸局部抗凝降低出血风险(2C)具有出血风险的患者可选择前列环素抗凝，但会引起血流动力学不稳定(2C)具有高出血风险的患者可采取无抗凝剂、盐水冲洗的方法，但引起超滤量增加，透析效率下降及增加了透析膜破裂的风险(2C),Guideline 10：RRT处方,通过对RRT剂量的评估确保透析充分性(1A)每次(IHD）或每日（CRRT)评估透析剂量及充分性(1A)推荐伴有多器官功能衰竭的AKI患者行CRRT，后稀释法超滤率25ml/kg/hr。前稀释法的持续性血液滤过相应的上调超滤率(1A)伴有多器官功能衰竭的AKI患者行间歇性血液透析治疗治疗时，必须达到单次透析URR 65%或eKt/V 1.2，或者进行每日透析(1B),CRRT剂量,We recommend delivering an effluent volume of 2025 ml/kg/h for CRRT in AKI (1A) . This will usually require a higher prescription of effluent volume. (Not Graded ),临床适应症,生化指标适应症,RRT开始指征 (1B),Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balanceexist. ( Not Graded),早期应用RRT治疗？,“早”：定义不统一BUN27mmol/L开始RRT，死亡风险翻倍,危重病人伴有AKI时CRRT与IHD的利弊,CRRT与IHD相比具备以下优点：稳定的血流动力学，缓慢、连续性清除液体和溶质，溶质清除率高; 持续稳定地控制氮质血症及电解质和水盐代谢;清除炎症介质，能够不断清除循环中存在的毒素和中小分子物质; 改善营养支持，保障营养补充及药物治疗,维持内环境稳定。缺点：花费大，机器昂贵，需要专业的医护团队，治疗期间不能外 出治疗、检查等。,当AKI作为多脏器功能衰竭的一部分，需要提前进入肾脏替代治疗(1C)AKI患者临床症状改善并出现肾功能恢复的早期征象应适当推迟RRT(1D)过早行RRT带来的问题静脉血栓的形成导管相关性感染抗凝治疗导致的出血其他并发症,CRRT与利尿剂,We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. ( 2B),Typical settin