crrt影响aki残余肾功能吗？课件

CRRT影响AKI残余肾功能吗？OutlineAKI的流行病学残余肾功能的概念及临床意义CRRT对残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-requiringARFbycalendaryearProspectiveobservationalstudySeptember2000toDecember2001at54hospitalsin23countriesOf29269criticallyillpatientsadmittedduringthestudyperiod,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:hazardratioof2.7EpidemiologyofAKIBloodPurif2011;31:159–171MulticenterItalianStudyRIFLE-BasedDataOutlineAKI的流行病学残余肾功能的概念及临床意义CRRT对残余肾功能的影响及可能机制小结残余肾功能(ResidualrenalfunctionRRF)定义：是指肾脏受到损伤后健存肾单位的残留功能，包括清除毒素、调节水电解质和酸碱平衡以及多种内分泌功能残余肾功能与AKI长期预后正相关IntensityofRenalSupport不改善AKI病死率NEnglJMed2008;359:7-20.NEnglJMed2009;361:1627-38.Onceanorganisinjured

TryandassistafailingorganbytreatingtheunderlyingcauseTrytoforcethatorgantoworkhardermaynotbethebestapproachResttheinjuredorganshouldbesensibleAvoidsignificantadverseevents

CriticalCare2012,16:317OutlineAKI的流行病学残余肾功能的概念及临床意义CRRT对残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/酸碱平衡能够不断清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++++++ComparedtoIRRT,CRRTcanhelptoraiseMAPTheCochraneLibrary2008,Issue3CRRTdecreasestherequiringofpressorTheCochraneLibrary2008,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.2007,33:773–780VeryhighrateofintradialytichypotensionintheIHDgroup–comparedtoCRRT/SLEDtreatments:TwiceasmanyIHDtreatmentsrequiredincreasedvasopressorsupportSixtimesasmanyIHDtreatmentshadtobestoppedRenalrecoveryratewaslowerthanexpected(~50%at28days)–possiblyrelatedtohypotensionduringIHDATNTrial:ImportantResultsDebateofrecoveryofrenalfunction

--ResultsofMetaanalysisMetaanalysisshowsnodifferenceinmortalityandchronicdialysisdependenceofpatientswithARFamongCRRT,IRRTorSLEDJAMA.2008;299(7):793-805SafetyCRRTRequirecontinuousanticoagulationTimeislongerIRRTRapidfluidandsoluteremovelBleedingDepletionofnutrientsInfectionHypotensionArrhythmiaHypothermiaismorefrequentduringCRRT,othercomplicationsaresimilarLancet2006;368:379–85OutlineAKI的流行病学残余