急性肾损伤诊疗指南解读

急性肾损伤(AKI)与急性肾衰竭(ARF)国际肾脏病和急救医学界将ARF改为急性肾损伤（AcuteKidneyInjury,AKI）。AKI覆盖的肾损伤

WarnockDG.JAmSocNephrol16:3149-3150,2006BiesenWVetal.CJASN.2006GFR正常伴肾脏损伤的标志物改变GFR开始下降GFR明显异常目前一页\总数五十一页\编于十二点AboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury目前二页\总数五十一页\编于十二点AKI流行病学现状患病率：1%（社区）~7.1%（医院）人群发病率：486~630pmp/yAKI需要RRT发病率：22~203pmp/y医院获得AKI死亡率：10~80%合并多脏器功能衰竭死亡率：>50%需要RRT治疗者死亡率：高达80%目前三页\总数五十一页\编于十二点指南推荐强度目前四页\总数五十一页\编于十二点指南推荐强度目前五页\总数五十一页\编于十二点Guideline1：AKI的定义与分期符合以下情况之一者即可被诊断为AKI：①

48小时内Scr升高超过26.5μmol/L(0.3

mg/dl)；②

Scr

升高超过基线1.5倍—确认或推测7天内发生；③

尿量＜0.5

ml/（kg·h），且持续6小时以上。单用尿量改变作为判断标准时，需要除外尿路梗阻及其它导致尿量减少的原因采用KDIGO推荐的定义和分期标准目前六页\总数五十一页\编于十二点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)目前七页\总数五十一页\编于十二点RIFLE分级2002年急性透析质量倡议组(ADQI)制定了ARF的RIFLE分级诊断标准。BellomoR,etal.CritCare2004;8:R204-R212目前八页\总数五十一页\编于十二点ConceptualmodelforAKI目前九页\总数五十一页\编于十二点Guideline2：临床评估2.1详细的病史采集和体格检查有助于AKI病因的判断(1A)2.224小时之内进行基本的检查，包括尿液分析和泌尿系超声(怀疑有尿路梗阻者)(1A)目前十页\总数五十一页\编于十二点Chapter2.2:Riskassessment目前十一页\总数五十一页\编于十二点Chapter2.2:Riskassessment目前十二页\总数五十一页\编于十二点AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.3mg/dl(X26.5lmol/l)within48hours;

·or

KIncreaseinSCrtoX1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;

·orKUrinevolumeo0.5ml/kg/hfor6hours.

TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)

Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)

EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)

DefinitionandstagingofAKI目前十三页\总数五十一页\编于十二点OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.目前十四页\总数五十一页\编于十二点AKD

acutekidneydiseasesanddisorder符合以下任何一项AKI,符合AKI定义3个月内在原来基础上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3个月肾损伤<3个月目前十五页\总数五十一页\编于十二点AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3个月>3个月AKDAKI3个月内在原来基础上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3个月<3个月NKD无异常目前十六页\总数五十一页\编于十二点Guideline3：PreventionandTreatmentofAKI3.1评估危险因素(1B)年龄>75岁CKD(eGFR<60ml/min/1.73m2心力衰竭动脉粥样硬化性周围血管病变肝脏疾病糖尿病肾毒性药物的使用低血容量感染3.2评估容量状态后适当补液(1B)HIGHRISK目前十七页\总数五十一页\编于十二点3.3造影剂肾病3.4继发于横纹肌溶解的AKI给予0.9%氯化钠和碳酸氢钠扩容(1B)对具CI-AKI高风险者：建议采用等渗或低渗造影剂建议口服或静脉使用N

-乙酰半胱氨酸（NAC）及等渗晶体预防CI-AKI推荐使用等渗氯化钠或碳酸氢钠静脉扩容以预防CI-AKI

目前十八页\总数五十一页\编于十二点Guideline4：AKI的治疗一般治疗(1A)目前十九页\总数五十一页\编于十二点Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKI目前二十页\总数五十一页\编于十二点补液治疗Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)目前二十一页\总数五十一页\编于十二点补液治疗：低血容量者：重复小剂量补液(250ml晶体液/胶体液）

密切监测CVP和尿量监测乳酸和碱剩余水平严重脓毒血症者：慎用高分子量羟乙基淀粉

目前二十二页\总数五十一页\编于十二点药物治疗(1B)多脏器功能衰竭药代动力学改变（分布容积、清除、与蛋白结合）需要调整药物剂量目前二十三页\总数五十一页\编于十二点目前无特殊的药物用于治疗继发于低灌注损伤/脓毒血症的AKI(1B)袢利尿剂againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425目前二十四页\总数五十一页\编于十二点Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)目前二十五页\总数五十一页\编于十二点Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;目前二十六页\总数五十一页\编于十二点Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;目前二十七页\总数五十一页\编于十二点TheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI.abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident.目前二十八页\总数五十一页\编于十二点甘露醇mannitolisnotscientificallyjustifiedinthepreventionofAKI.目前二十九页\总数五十一页\编于十二点Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWerecommendnotusinglow-dosedopaminetopreventortreatAKI.（1A）Wesuggestnotusingfenoldopam（非诺多巴）topreventortreatAKI.(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKI目前三十页\总数五十一页\编于十二点Effectoflow-dosedopamineonmortality.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；目前三十一页\总数五十一页\编于十二点多巴胺---不建议FriedrichJO,AdhikariN,HerridgeMS.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510-524降低肾灌注(Lauschke,KidneyInt2006)导致心律失常(Schenarts,CurrentSurgery2006)加重心肌、肠道缺血缺氧(Schenarts,CurrentSurgery2006)非诺多巴---不建议选择性多巴胺A1受体激动剂，在降低全身血管阻力的同时增加肾血流量RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.1mg/kg/min,forthepreventionortreatmentofAKI.ThereisapossibilitythatANPmightbeeffectiveifitisgivenatalowerdose(0.01–0.05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；目前三十二页\总数五十一页\编于十二点GlycemiccontrolandnutritionalsupportIncriticallyillpatients,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）目前三十三页\总数五十一页\编于十二点GrowthfactorinterventionWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.（1B）humanIGF-1：重组人胰岛素样生长因子1目前三十四页\总数五十一页\编于十二点Preventionofaminoglycoside-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)目前三十五页\总数五十一页\编于十二点Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB.(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.(1A)目前三十六页\总数五十一页\编于十二点OthermethodsofpreventionofAKI

inthecriticallyillWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT.(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.(2D)Werecommendnotusingoralori.v.NACforpreventionofpostsurgicalAKI.(1A)CI-AKI:预防对比剂急性肾损害目前三十七页\总数五十一页\编于十二点Guideline5：医疗资源合理分配多学科参与AKI指南制定肾科医生会诊提供专科意见合理的转诊方案密切监护治疗肾脏科与ICU医生协作Whentorequestarenalreferral？目前三十八页\总数五十一页\编于十二点Guideline6：RRT模式的选择建议个体化治疗！(1B)Kanagasundaram,2007目前三十九页\总数五十一页\编于十二点Guideline7：

透析器和透析液的选择透析器：合成膜透析器(1B)改良纤维素膜透析器(1B)透析液：首选碳酸氢钠透析液/置换液(1C)透析液微生物的控制目前四十页\总数五十一页\编于十二点Guideline8：血管通路临时建立静脉-静脉通路(1A)选择足够长度的透析导管以降低再循环率(1B)置管部位和导管类型需根据患者的病情选择(2C)由经验丰富的医生负责置管(1A)实时超声导引有助于置管(1D)对有进展至CKD4-5期风险的患者，尽量避免行锁骨下静脉置管，保护患者的血管资源(1D)目前四十一页\总数五十一页\编于十二点Guideline8：血管通路保护非优势侧的上肢血管(2C)定期更换临时导管以降低感染的风险(1C)颈内静脉：3周股静脉：1周>3周：建议用皮下隧道导管导管仅限于RRT治疗时使用(1D)以预防感染目前四十二页\总数五十一页\编于十二点Guideline9：体外抗凝根据患者病情和RRT模式制定抗凝治疗方案(1C)推荐枸橼酸局部抗凝降低出血风险(2C)具有出血风险的患者可选择前列环素抗凝，但会引起血流动力学不稳定(2C)具有高出血风险的患者可采取无抗凝剂、盐水冲洗的方法，但引起超滤量增加，透析效率下降及增加了透析膜破裂的风险(2C)目前四十三页\总数五十一页\编于十二点Guideline10：RRT处方通过对RRT剂量的评估确保透析充分性(1A)每次(IHD）或每日（CRRT)评估透析剂量及充分性(1A)推荐伴有多器官功能衰竭的AKI患者行CRRT，后稀释法超滤率>25ml/kg/hr。前稀释法的持续性血液滤过相应的上调超滤率(1A)伴有多器官功能衰竭的AKI患者行间歇性血液透析治疗治疗时，必须达到单次透析URR>65%或eKt/V>1.2，或者进行每日透析(1B)目前四十四页\总数五十一页\编于十二点CRRT剂量Werecommenddeliveringaneffluentvolumeof20–25ml/kg/hforCRRTinAKI(1A).Thiswillusuallyrequire