KDIGOAKI急性肾损伤诊疗指南解读

KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury,2012

KDIGO：KidneyDiseaseImprovingGlobalOutcomesAboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury指南推荐强度QualityofevidenceA－HighB－ModerateC－LowD－VerylowStrengthofrecommendationLevel1－strongLevel2－weakordiscretionary指南推荐强度AKIisdefinedasanyofthefollowing(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:RiskassessmentChapter2.2:RiskassessmentOverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.AKI/CKD/AKDGuideline3：PreventionandTreatmentofAKIHIGHRISKStage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIGuidline3Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)DiureticsagainstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)TheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI.MannitolisnotscientificallyjustifiedinthepreventionofAKI.Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWerecommendnotusinglow-dosedopaminetopreventortreatAKI.（1A）Wesuggestnotusingfenoldopam（非诺多巴）topreventortreatAKI.(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKIGlycemiccontrolandnutritionalsupportIncriticallyillpatients,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）GrowthfactorinterventionWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.（1B）humanIGF-1：重组人胰岛素样生长因子1Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestnotusingaminoglycosidesforthetreat-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-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB.(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.(1A)GuidlineWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT.(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.(2D)Werecommendnotusingoralori.v.NACforpreventionofpostsurgicalAKI.(1A)GuidlineInitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.(NotGraded)Considerthebroaderclinicalcontext,thepresenceofconditionsthatcanbemodifiedwithRRT,a