crrt影响aki残余肾功能吗？PPT课件.ppt

Outline,AKI 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-based incidence rates(per 100 000 person-years)of non dialysis requiring ARF by calendar year,Kidney Int,2007;72(2):208212,Community-based incidence rates(per 100 000 person-years)of dialysis-requiring ARF by calendar year,ARF病死率居高不下,J Am Soc Nephrol,2006;17:11431150,ARF、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%,Prospective observational study September 2000 to December 2001 at 54 hospitals in 23 countriesOf 29 269 critically ill patients admitted during the study period,1738(5.7%;95%CI 5.5%-6.0%)had ARF during their ICU stay,including 1260 who were treated with RRT,JAMA.2005;294:813-818,The criteria for ARF：少尿(12小时200ml)或/和血尿素氮高于84 mg/dL(30 mmol/L),Mortality with acute kidney failure,JAMA.2005;294:813-818,Overall hospital mortality was 60.3%,RIFLE criteria:incidence and associated mortality,Critical Care 2006,10:R73,5383 critically ill patients in 7 ICUs,AKI occurred in 67%of patientsMortality:hazard ratio of 2.7,Has mortality from acute renal failure decreased?,The American Journal of Medicine(2005)118,827832,Reported mortality rates of patients with acute renal failure from 1956 to 2003-A systematic review of the literature-47years80 were included in our review with a total of 15 897 patients,Epidemiology of AKI,Blood Purif 2011;31:159171,Multicenter Italian Study,RIFLE-Based Data,Outline,AKI 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(Residual renal function RRF),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,残余肾功能与生存率,Nephrol Dial Transplant 2005;20:396403Nephrol Dial Transplant.2011;26(9):2978-83.,残余肾功能与AKI长期预后正相关,Intensity of Renal Support不改善AKI病死率,N Engl J Med 2008;359:7-20.,N Engl J Med 2009;361:1627-38.,Once an organ is injured Try and assist a failing organ by treating the underlying causeTry to force that organ to work harder may not be the best approachRest the injured organ should be sensibleAvoid significant adverse events,Critical Care 2012,16:317,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,J Am Soc Nephrol.2000 Mar;11:556-64.,Outline,AKI 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,CRRT vs IRRT,Recovery of renal function-In theory,Nephrology Dialysis Transplantation 1997;12(5):8702,Compared to IRRT,CRRT can help to raise MAP,The Cochrane Library 2008,Issue 3,CRRT decreases the requiring of pressor,The Cochrane Library 2008,Issue 3,CRRT is associated with more stable haemodynamics than IRRT,Retrospective cohort study Pats with ARF and required dialysis between April 1,1996,and March 31,19992 ICU in Canada.N=261,CRRT对ARF肾功能恢复的影响CRRT促进肾功能恢复,Crit Care Med 2003;31:449 455,CRRT：肾功能恢复,32 ICU，n=22021102 Survived 90 daysCVVH：944（85.7%）IHD：158（14.3%）,Intensive Care Med(2007)33:773780,慢性透析8.3%,慢性透析16.5%,944 CRRT,1102 存活90天,78 90天内 慢性透析,26 90天内 慢性透析,158 IHD,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,1218 patients for ARF in 54 ICU in 23 countries,Int J Artif Organs 2007;30(4):281-292,肾功能恢复,CRRT能促进肾功能恢复,DesignRetrospective cohort study32 Swedish ICUs2,202 patients with ARF(exclude ESRD),Intensive Care Med.2007,33:773780,VA/NIH Acute Renal Failure Trial Network(ATN)Study,1124 patients 27 sites 3 years,Intensive Management Strategy(561 patients),Randomization,Less Intensive Management Strategy(563 patients),N Engl J Med 2008;359:7-20,No difference on 60 days mortality,KaplanMeier Plot of Cumulative Probabilities of Death,Very high rate of intradialytic hypotension in the IHD group compared to CRRT/SLED treatments:Twice as many IHD treatments required increased vasopressor supportSix times as many IHD treatments had to be stopped Renal recovery rate was lower than expected(50%at 28 days)possibly related to hypotension during IHD,ATN Trial:Important Results,Debate of recovery of renal function-Results of Meta analysis,Meta analysis shows no difference in mortality and chronic dialysis dependence of patients with ARF among CRRT,IRRT or SLED,JAMA.2008;299(7):793-805,Safety,CRRTRequire continuous anticoagulationTime is longer,IRRTRapid fluid and solute removel,BleedingDepletion of nutrientsInfection,HypotensionArrhythmia,Hypothermia is more frequent during CRRT,other complications are similar,Lancet 2006;368:37985,Outline,AKI 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,Factors influenced our choice,与IHD比较，CRRT有利于残余肾功能恢复,