crrt影响aki残余肾功能吗？课件

CRRT影响AKI剩余肾功能吗？OutlineAKI的流行病学剩余肾功能的概念及临床意义CRRT对剩余肾功能的影响及可能机制小结ARF的现状-发生率逐年增加Community-basedincidencerates(per100000person-years)ofnondialysisrequiringARFbycalendaryearKidneyInt,2007;72(2):208–212Community-basedincidencerates(per100000person-years)ofdialysis-requiringARFbycalendaryearARF病死率居高不下JAmSocNephrol,2006;17:1143–1150ARF、ARF-D的发病率仍呈上升趋势ARF病死率随时间尽管呈下降趋势，但是仍然高达25-40%ProspectiveobservationalstudySeptember2000toDecember2001at54hospitalsin23countriesOf29269criticallyillpatientsadmittedduringthestudyperiod,1738(5.7%;95%CI5.5%-6.0%)hadARFduringtheirICUstay,including1260whoweretreatedwithRRTJAMA.2005;294:813-818ThecriteriaforARF：少尿(12小时<200ml)或/和血尿素氮高于84mg/dL(30mmol/L)MortalitywithacutekidneyfailureJAMA.2005;294:813-818Overallhospitalmortalitywas60.3%RIFLEcriteria:incidenceandassociatedmortalityCriticalCare2006,10:R735383criticallyillpatientsin7ICUs,AKIoccurredin67%ofpatientsMortality:hazardratioof2.7Hasmortalityfromacuterenalfailuredecreased?TheAmericanJournalofMedicine(2005)118,827–832Reportedmortalityratesofpatientswithacuterenalfailurefrom1956to2003--Asystematicreviewoftheliterature-47years80wereincludedinourreviewwithatotalof15897patientsEpidemiologyofAKIBloodPurif2021;31:159–171MulticenterItalianStudyRIFLE-BasedDataOutlineAKI的流行病学剩余肾功能的概念及临床意义CRRT对剩余肾功能的影响及可能机制小结剩余肾功能(ResidualrenalfunctionRRF)定义：是指肾脏受到损伤后健存肾单位的残留功能，包括去除毒素、调节水电解质和酸碱平衡以及多种内分泌功能剩余肾功能与生存率NephrolDialTransplant2005;20:396–403NephrolDialTransplant.2021;26(9):2978-83.剩余肾功能与AKI长期预后正相关IntensityofRenalSupport不改善AKI病死率NEnglJMed2021;359:7-20.NEnglJMed2021;361:1627-38.Onceanorganisinjured

TryandassistafailingorganbytreatingtheunderlyingcauseTrytoforcethatorgantoworkhardermaynotbethebestapproachResttheinjuredorganshouldbesensibleAvoidsignificantadverseeventsCriticalCare2021,16:317在维持性透析患者中影响RRF的因素血压年龄性别种族药物钙磷代谢脂质代谢内分泌激素水平肾脏替代治疗相关因素〔腹膜透析or血透、透析膜等〕其他JAmSocNephrol.2000Mar;11:556-64.OutlineAKI的流行病学剩余肾功能的概念及临床意义CRRT对剩余肾功能的影响及可能机制小结CRRT特点稳定的血流动力学持续稳定的控制氮质血症和水电/酸碱平衡能够不断去除循环中的毒素或中分子物质按需提供营养补充和药物治疗CRRTvsIRRTIHDPDCRRTHemodynamicstability…+++Osmopressurestability…++++Fluidremoval++++++Correctionofacidosis++++++UnlimitedPN/EN……++ClearancesSmallsolutes(<500d)++++++Largesolutes(>500d)…++++Mediatorremoval……++?Accessmorbidity++++Anticoagulationneeds+…+Simplicity++++++Recoveryofrenalfunction--IntheoryRemovefluidandsoluteslowlyMorestableHaemodynamicsMayhelptorevoveryofrenalfunctionCRRTRapidfluidremovalMayleadtohypotensionWithpotentialforfurtherrenalinjuryandprolongationofARFIRRTNephrologyDialysisTransplantation1997;12(5):870–2ComparedtoIRRT,CRRTcanhelptoraiseMAPTheCochraneLibrary2021,Issue3CRRTdecreasestherequiringofpressorTheCochraneLibrary2021,Issue3CRRTisassociatedwithmorestablehaemodynamicsthanIRRTRetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,19992ICUinCanada.N=261CRRTIHDPAPACHEII2725.10.10BaselineSCr1361800.002MAPBeforeRRT74.787.2<0.001HospMortality71.9%42.2%<0.01Renalrecoveryinhosp80.0%62.5%0.06DurationofRRT14.7d14.5d0.91Costperweek(Can$)3486-51171341Survivor(Costpery)No-RRTRRT$11,192$73,273CRRT对ARF肾功能恢复的影响

－CRRT促进肾功能恢复CritCareMed2003;31:449–455CRRT：肾功能恢复32ICU，n=22021102Survived90daysCVVH：944〔85.7%〕IHD：158〔14.3%〕IntensiveCareMed(2007)33:773–780慢性透析8.3%慢性透析16.5%944CRRT1102存活90天7890天内

慢性透析2690天内

慢性透析158IHD结论：CRRT更有利于肾功能的恢复，但病死率无差异。CRRT：肾功能恢复1218patientsforARFin54ICUin23countriesIntJArtifOrgans2007;30(4):281-292肾功能恢复CRRT能促进肾功能恢复DesignRetrospectivecohortstudy32SwedishICUs2,202patientswithARF(excludeESRD)IntensiveCareMed.2007,33:773–780VA/NIHAcuteRenalFailure

TrialNetwork(ATN)Study1124patients27sites3yearsIntensiveManagementStrategy

(561patients)RandomizationStablehemodynamics(SOFA0-2)IHD6x/week@Kt/Vof~1.2/sessionIHD3x/week@Kt/Vof~1.2/sessionUnstablehemodynamics(SOFA3-4)CVVHDF@

35mL/kg/hr,orSLED/EDD6x/weekCVVHDF@

20mL/kg/hr,orSLED/EDD3x/weekLessIntensiveManagementStrategy

(563patients)NEnglJMed2021;359:7-20Nodifferenceon60daysmortalityKaplan–MeierPlotofCumulativeProbabilitiesofDeathVeryhighrateofintradialytichypotensionintheIHDgroup–comparedtoCRRT/SLEDtreatments:TwiceasmanyIHDtreatmentsrequiredincreasedvasopressorsupportSixtimesasmanyIHDtreatmentshadtobestoppedRenalrecoveryratewaslowerthanexpected(~50%at28days)–possiblyrelatedtohypotensionduringIHDATNTrial:ImportantResultsDebateofrecoveryofrenalfunction

--ResultsofMetaanalysisMetaanalysisshowsnodifferenceinmortalityandchronicdialysisdependenceofpatientswithARFamongCRRT,IRRTorSLEDJAMA.2021;299(7):793-805SafetyCRRTRequirecontinuousanticoagulationTimeislongerIRRTRapidfluidandsoluteremovelBleedingDepletionofnutrientsInfectionHypotensionArrhythmiaHypothermiaismorefrequentd