KDIGO-AKI急性肾损伤诊疗指南解读2012版5

1、KDIGO,2012于立杰KDIGO：Kidney Disease Improving Global OutcomesKDIGO,2012 ADQI：2002, RIFLE AKIN：2005, modified definition and staging system KDIGO: 2011, First clinical guideline for AKI Waiting for published in this summer AKI guideline for AKI :2011 UK Renal Association Final Version 08.03.11 AKI guid

2、lineKDIGO 2012 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKDIGO,2012Quality of evidenceAHighBModerateCLowDVery lowStrength of recommendationLevel1strongLevel2weak or discretionaryKDIGO,2012KDIGO,2012 Increase in SCr by 0.3mg/dl (X26.5 mol/l) within 48 hours; or Increase in SCr to1.5 ti

3、mes baseline, which is known or presumed to have occurred within the prior 7 days; or Urine volume 0.5ml/kg/h for 6 hours.KDIGO,2012AKI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)KDIGO,2012KDIGO,2012KDIGO,2012KDIGO,2012KDIGO,2012KDIGO,2012HIGHRISKKDIGO,2012Chapter 2.3:Evaluation and general management of patien

4、ts with and at risk for AKIKDIGO,2012 In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI. (2B) We recommend the use of vasopressors i

5、n conjunction with fluids in patients with vasomotor shock with, or at risk for AKI. ( 1C) We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting (2C) or in patients with septi

6、c shock (2C)KDIGO,2012DiureticsagainstMehta RL, Pascual MT, Soroko S et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002; 288: 2547-2553 Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333 (7565): 420-425

7、KDIGO,2012 We recommend not using diuretics to prevent AKI. (1B) We suggest not using diuretics to treat AKI, exceptin the management of volume overload. ( 2C)KDIGO,2012 At present, the current evidence does not suggest that furosemide can reduce mortality in patients with AKI. Mannitol is not scien

8、tifically justified in the prevention of AKI.KDIGO,2012 We recommend not using low-dose dopamine to prevent or treat AKI. （1A） We suggest not using fenoldopam（非诺多巴）to prevent or treat AKI. ( 2C) We suggest not using atrial natriuretic peptide(ANP) to prevent (2C) or treat ( 2B) AKIKDIGO,2012In criti

9、cally ill patients, we suggest insulin therapy targeting plasma glucose 110149 mg/dl(6.18.3 mmol/l). ( 2C)We suggest achieving a total energy intake of 2030 kcal/kg/d in patients with any stage of AKI. (2C)We suggest to avoid restriction of protein intake with the aim of preventing or delaying initi

10、ation of RRT. ( 2D)We suggest administering 0.81.0 g/kg/d of protein in non catabolic AKI patients without need for dialysis ( 2D), 1.01.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patie

11、nts. ( 2D)We suggest providing nutrition preferentially via the enteral route in patients with AKI. (2C）KDIGO,2012 We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI. （1B）human IGF-1：重组人胰岛素样生长因子1 KDIGO,2012We suggest not using aminoglycosides for the treat-ment of infections

12、unless no suitable, less nephro-toxic, therapeutic alternatives are available. (2A)We suggest that, in patients with normal kidney function in steady state, aminoglycosides are administered as a single dose daily rather than multiple-dose daily treatment regimens. (2B)We recommend monitoring aminogl

13、ycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A)We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used for more than 48 hours. (2C)We suggest using topical or local applications of aminoglycosides (e.g., resp

14、iratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. ( 2B)KDIGO,2012 We suggest using lipid formulations of ampho-tericin B rather than conventional formulations of amphotericin B. (2A) In the treatment of systemic mycoses or parasitic infections,

15、we recommend using azole antifungal agents and/or the echinocandins rather than conventional amphotericin B, if equal therapeutic efficacy can be assumed.(1A)KDIGO,2012 We suggest that off-pump coronary artery bypass graft surgery not be selected solely for the purpose of reducing perioperative AKI

16、or need for RRT. (2C) We suggest not using NAC to prevent AKI in critically ill patients with hypotension. (2D) We recommend not using oral or i.v. NAC for prevention of postsurgical AKI. (1A)KDIGO,2012 Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balanc

17、e exist.(Not Graded) Consider the broader clinical context, the presence of conditions that can be modified with RRT, and trends of laboratory testsrather than single BUN and creatinine thresholds alonewhen making the decision to start RRT. (Not Graded)KDIGO,2012 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; Last choice: sub