KDIGO急性肾损伤指南解读

KDIGO急性肾损伤指南解读,KDIGO Clinical Practice Guideline for Acute Kidney Injury,Kidney inter. Suppl. 2012; 2: 1138,GRADE 系统,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:9 14.8%,1B:10 16.4%,1C:3 4.9%,2A:2 3.3%,2B:10 16.4%,2C:20 32.8%,2D:7 11.5%,内容,Introduction and MethodologyAKI DefinitionPrevention and Treatment of AKIContrast-induced AKIDialysis Interventions for Treatment of AKI,符合下列任何一条即可诊断 1. Increase in SCr by 0.3 mg/dl ( 26.5 lmol/l) within 48 hours2. Increase in SCr to 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days3. Urine volume 0.5 ml/kg/h for 6 hours.,AKI 诊断(Not Graded),Stage Serum creatinine Urine output1 1.51.9 times baseline OR 0.5 ml/kg/h for 0.3 mg/dl ( 26.5 mmol/l) increase 612 hours2 2.02.9 times baseline 0.5 ml/kg/h for 12 hours3 3.0 times baseline OR Increase in serum creatinine to 0.3 ml/kg/h for 4.0 mg/dl ( 353.6 mmol/l) 24 hours OR OR Initiation of renal replacement therapy Anuria for 12 hours OR, In patients 18 years, decrease in eGFR to 35 ml/min per 1.73 m2,AKI 分级(Not Graded),The cause of AKI should be determined wheneverpossible. (Not Graded),Selected causes of AKI requiringimmediate diagnosis and specifictherapies Recommended diagnostic testsDecreased kidney perfusion Volume status and urinary diagnostic indicesAcute glomerulonephritis, vasculitis, Urine sediment examination,interstitial nephritis, thrombotic serologic testing andMicroangiopathy hematologic testing Urinary tract obstruction Kidney ultrasound,We recommend that patients be stratified for risk of AKI according to their susceptibilities and exposures. (1B) Manage patients according to their susceptibilities and exposures to reduce the risk of AKI . (Not Graded)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),Exposures SusceptibilitiesSepsis Dehydration or volume depletionCritical illness Advanced ageCirculatory shock Female genderBurns Black raceTrauma CKDCardiac surgery (especially Chronic diseases (heart, lung, liver)with CPB) Major noncardiac surgery Diabetes mellitusNephrotoxic drugs CancerRadiocontrast agents AnemiaPoisonous plants and animals,Causes of AKI: exposures and susceptibilities for non-specific AKI,Evaluate patients with AKI promptly to determinethe cause, with special attention to reversiblecauses. (Not Graded) Monitor patients with AKI with measurements ofSCr and urine output to stage the severity, according to Recommendation . (Not Graded) Manage patients with AKI according to the stage and cause. (Not Graded),AKI时RRT治疗时机,Initiate RRT emergently when life-threateningchanges in fluid, electrolyte, and acid-base balance exist. (Not Graded)Consider the broader clinical context, the presenceof conditions that can be modified with RRT, andtrends of laboratory testsrather than single BUNand creatinine thresholds alonewhen making thedecision to start RRT. (Not Graded),Potential applications for RRT,Applications CommentsRenal replacement This is the traditional, prevailing approach based on utilization of RRT when there is little or no residual kidney function.Life-threatening indications No trials to validate these criteria.Hyperkalemia Dialysis for hyperkalemia is effective in removing potassium; however, it requires frequent monitoring of potassium levels and adjustment of concurrent medical management to prevent relapses.Acidemia Metabolic acidosis due to AKI is often aggravated by the underlying condition. Correction of metabolic acidosis with RRT in these conditions depends on the underlying disease process.Pulmonary edema RRT is often utilized to prevent the need for ventilatory support; however, it is equally important to manage pulmonary edema in ventilated patients.Uremic complications(pericarditis, bleeding, etc.) In contemporary practice it is rare to wait to initiate RRT in AKI patients until there are uremic complications,Potential applications for RRT,Applications CommentsNonemergent indicationsSolute control BUN reflects factors not directly associated with kidney function, such as catabolic rate and volume status.SCr is influenced by age, race, muscle mass, and catabolic rate, and by changes in its volume of distribution due to fluid administration or withdrawal.Fluid removal Fluid overload is an important determinant of the timing of RRT initiation.Correction of acid-baseAbnormalities No standard criteria for initiating dialysis exist.,Potential applications for RRT,Applications CommentsRenal support This approach is based on the utilization of RRT techniques as an adjunct to enhance kidney function, modify fluid balance, and control solute levels.Volume control Fluid overload is emerging as an important factor associated with, and possibly contributing to, adverse outcomes in AKI. Recent studies have shown potential benefits from extracorporeal fluid removal in CHF. Intraoperative fluid removal using modified ultrafiltration has been shown to improve outcomes in pediatric cardiac surgery patients.Nutrition Restricting volume administration in the setting of oliguric AKI may result in limited nutritional support and RRT allows better nutritional supplementation.Drug delivery RRT support can enhances the ability to administer drugs without concerns about concurrent fluid accumulation.Regulation of Permissive hypercapnic acidosis in patients with lung injury can be corrected acid-base with RRT, without inducing fluid overload and hypernatremia.and electrolyte statusSolute Changes in solute burden should be anticipated (e.g., tumor lysis modulation syndrome). Although current evidence is unclear, studies are ongoing to assess the efficacy of RRT for cytokine manipulation in sepsis.,AKI时停用RRT指征,Discontinue RRT when it is no longer required,either because intrinsic kidney function has recovered to the point that it is adequate to meet patient needs, or because RRT is no longer consistent with the goals of care. (Not Graded),We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. (2B),抗凝治疗,In a patient with AKI requiring RRT, base the decision to use anticoagulation for RRT on assessment of the patients potential risks and benefits from anticoagulation . (Not Graded),We recommend using anticoagulation during RRT in AKI if a patient does not have an increased bleeding risk or impaired coagulation and is not already receiving systemic anticoagulation. (1B),For patients without an increased bleeding risk or impaired coagulation and not already receiving effective systemic anticoagulation, we suggest the following:,For anticoagulation in intermittent RRT, we recommend using either unfractionated or low-molecular-weight heparin,rather than other anticoagulants. (1C),For anticoagulation in CRRT, we suggest using regional citrate anticoagulation rather than heparin in patients who do not have contraindications for citrate. (2B),For anticoagulation during CRRT in patients who have contraindications for citrate, we suggest using either unfractionatedor low-molecular-weight heparin, rather than other anticoagulants. (2C),抗凝治疗,For patients with increased bleeding risk who are not receiving anticoagulation, we suggest the following for anticoagulation during RRT:,We suggest using regional citrate anticoagulation,rather than no anticoagulation, during CRRT in a patient without contraindications for citrate. (2C),We suggest avoiding regional heparinization during CRRT in a patient with increased risk of bleeding. (2C),抗凝治疗,In a patient with heparin-induced thrombocytopenia(HIT), all heparin must be stopped and we recommend using direct thrombin inhibitors (such as argatroban) or Factor Xa inhibitors (such as danaparoid or fondaparinux) rather than other or no anticoagulation during RRT. (1A),In a patient with HIT who does not have severe liver failure, we suggest using argatroban rather than other thrombin or Factor Xa inhibitors during RRT. (2C),抗凝治疗,血管通路,We suggest initiating RRT in patients with AKI viaan uncuffed nontunneled dialysis catheter, ratherthan a tunneled catheter. (2D),When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these preferences (Not Graded):* First choice: right jugular vein;* Second choice: femoral vein;* Third choice: left jugular vein;*Last choice: subclavian vein with preference for the dominant side.,We recommend using ultrasound guidance fordialysis catheter insertion. (1A),We recommend obtaining a chest radiographpromptly after placement and before first use of aninternal jugular or subclavian dialysis catheter. (1B),We suggest not using topical antibiotics over theskin insertion site of a nontunneled dialysis catheterin ICU patients with AKI requiring RRT. (2C),We suggest not using antibiotic locks for preventionof catheter-related infections of nontunneleddialysis catheters in AKI requiring RRT. (2C),血管通路,滤器选择,We suggest to use dialyzers with a biocompatiblemembrane for IHD and CRRT in patients withAKI. (2C),RRT模式选择,Use continuous and intermittent RRT as complementarytherapies in AKI patients. (Not Graded),We suggest using CRRT, rather than standardintermittent RRT, for hemodynamically unstablepatients. (2B),We suggest using CRRT, rather than intermittentRRT, for AKI patients with acute brain injury orother causes of increased intracranial pressure orgeneralized brain edema. (2B),Typical setting of different RRT modalities for AKI (for 70-kg patient),Theoretical advantages and disadvantages of CRRT, IHD, SLED, and PD,缓冲液的选择,We suggest using bicarbonate, rather than lactate,as a buffer in dialysate and replacement fluid forRRT in patients with AKI. (2C) We recommend using bicarbonate, rather thanlactate, as a buffer in dialysate and replacementfluid for RRT in patients with AKI and circulatorysho