急性肾损伤诊疗指南解读培训课件.ppt

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1、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（Acute Kidney Injury, AKI）。AKI 覆盖的肾损伤,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006Biesen WV et al. CJASN. 2006,急性肾损伤(AKI)与急性肾衰竭(ARF)国际肾脏病和急救医,About AKI guideline,ADQI：2002, RIFLEAKIN：2005, modified definition and staging systemKDIGO: 2011, First clinica

2、l guideline for AKIWaiting for published in this summerAKI guideline for AKI :2011UK Renal Association Final Version 08.03.11AKI guidlineKDIGO 2012KDIGO Clinical Practice Guideline for Acute Kidney Injury,About AKI guidelineADQI：2002,AKI流行病学现状,患病率：1%（社区） 7.1%（医院）人群发病率：486630 pmp/yAKI需要RRT发病率：22203pm

3、p/y医院获得AKI死亡率：1080%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%,AKI流行病学现状患病率：1%（社区） 7.1%（医院）,指南推荐强度,指南推荐强度,指南推荐强度,指南推荐强度,Guideline 1：AKI的定义与分期,符合以下情况之一者即可被诊断为AKI：48小时内Scr升高超过26.5mol/L(0.3mg/dl)；Scr升高超过基线1.5倍确认或推测7天内发生；尿量0.5ml/（kgh），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,Guideline 1：AKI的定

4、义与分期符合以下情况之一者,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),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,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。,Bellomo R, et al. Crit Care 2004;8:R204-R212,RIFLE分级2002 年急性透析质量倡议组(ADQI)制定,Conceptual model for AKI,Conceptual model for AKI,Guideline 2：临床评估,2.1 详细的病史采集和体格检查有助于AKI病因

5、的判断(1A)2.2 24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),Guideline 2：临床评估2.1 详细的病史采集和体格,Chapter 2.2: Risk assessment,Chapter 2.2: Risk assessment,Chapter 2.2: Risk assessment,Chapter 2.2: Risk assessment,AKI is defined as any of the following (Not Graded ): AKI is defined as any of the following (Not Gra

6、ded ): KIncrease in SCr by X 0.3 mg/dl ( X26.5 lmol/l)within 48 hours; or KIncrease in SCr to X1.5 times baseline, whichis known or presumed to have occurred withinthe prior 7 days; orKUrine volume o0.5 ml/kg/h for 6 hours.Test patients at increased risk for AKI with measurements of SCr and urine ou

7、tput to detect AKI. ( Not Graded )Individualize frequency and duration of monitoring based on patient risk and clinical course. ( Not Graded ) Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes.(Not Graded ) he cause of AKI should be determined wh

8、enever possible. (Not Graded),Definition and staging of AKI,AKI is defined as any of the,Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, o

9、r CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.,Overview of AKI, CKD, and AKD.,AKDacute kidney diseases and disorder,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%GFR60ml/min/1.73m2, 3个月肾损伤3个

10、月,AKDacute kidney diseases and,AKI/CKD/AKD,AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌,Guideline 3：Prevention and Treatment of AKI,3.1评估危险因素(1B)年龄75岁CKD (eGFR60ml/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,Guideline 3：Prevention and Tre,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

11、),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,3.3造影剂肾病3.4继发于横纹肌溶解的AKI对具CI-AK,Guideline 4：AKI的治疗,一般治疗(1A),Guideline 4：AKI的治疗一般治疗(1A),Stage-based management of AKI,Chapter 2.3:Evaluation and general management ofpatients with and at risk for AKI,Stage-based

12、management of AKIC,补液治疗,In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion ofintravascular volume in patients at risk for AKI or with AKI. (2B)We recommend the use of vasopressors in conjunction wi

13、th fluids in patients with vasomotor shock with, or at risk for AKI. ( 1C) We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting (2C) or in patients with septic shock (2C),补液治

14、疗In the absence of hemorrha,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,补液治疗：,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,药物治疗(1B)多脏器功能衰竭,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,against,Mehta RL, Pascual MT, Soroko S et al. Diuretics, mortality, and nonrecovery of

15、renal function in acute renal failure. JAMA 2002; 288: 2547-2553 Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333 (7565): 420-425,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,Chapter 3.4: The use of diuretics in AKI,We recommend not using diuretics to prevent AK

16、I. (1B)We suggest not using diuretics to treat AKI, exceptin the management of volume overload. ( 2C),Chapter 3.4: The use of diuret,Effect of furosemide vs. control on all-cause mortality. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65:

17、 283293 with permission from John Wiley and Sons193;,Effect of furosemide vs. contr,Effect of furosemide vs. control on need for RRT. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283293 with permission from John Wiley and Sons193;,Eff

18、ect of furosemide vs. contr,The use of diuretics in AKI,At present, thecurrent evidence does not suggest that furosemide can reduce mortality in patients with AKI.a beneficial role for loop diuretics in facilitatingdiscontinuation of RRT in AKI is not evident.,The use of diuretics in AKIAt,甘露醇,manni

19、tol is not scientifically justified in the prevention of AKI.,甘露醇mannitol is not scientifica,Vasodilator therapy: dopamine,fenoldopam, and natriuretic peptides,We recommend not using low-dose dopamine toprevent or treat AKI. （1A）We suggest not using fenoldopam（非诺多巴）to prevent or treat AKI. ( 2C)We s

20、uggest not using atrial natriuretic peptide(ANP) to prevent (2C) or treat ( 2B) AKI,Vasodilator therapy: dopamine,Effect of low-dose dopamine on mortality. Reprinted from Friedrich JO, Adhikari N, Herridge MSet al . Meta-analysis: low-dosedopamine increases urine output but does not prevent renal dy

21、sfunction or death.Ann Intern Med 2005; 142: 510524 with permissionfrom American College of Physicians212；,Effect of low-dose dopamine on,多巴胺-不建议,Friedrich JO, Adhikari N, Herridge MS. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern

22、 Med 2005; 142: 510-524,降低肾灌注(Lauschke , Kidney Int 2006)导致心律失常(Schenarts , Current Surgery 2006)加重心肌、肠道缺血缺氧(Schenarts , Current Surgery 2006),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,RESEARCH RECOMMENDATION：We recommend further trials of ANP at doses below 0.1m g/kg/min, for the prevention or trea

23、tment of AKI.There is a possibility that ANP might be effective if it isgiven at a lower dose (0.010.05 mg/kg/min) in patients prophylactically or with early AKI, and during a longer period than in previous large studie；,多巴胺-不建议Friedrich JO, Adhikar,Glycemic control and nutritional support,In critic

24、ally ill patients, we suggest insulin therapy targeting plasma glucose 110149 mg/dl(6.18.3 mmol/l). ( 2C)We suggest achieving a total energy intake of 2030 kcal/kg/d in patients with any stage of AKI. (2C)We suggest to avoid restriction of protein intake with the aim of preventing or delaying initia

25、tion of RRT. ( 2D)We suggest administering 0.81.0 g/kg/d of protein in non catabolic AKI patients without need fordialysis ( 2D), 1.01.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patient

26、s. ( 2D)We suggest providing nutrition preferentially via the enteral route in patients with AKI. (2C）,Glycemic control and nutrition,Growth factor intervention,We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI. （1B）,human IGF-1：重组人胰岛素样生长因子1,Growth factor interventionWe r,Pr

27、evention of aminoglycoside- andamphotericin-related AKI,We suggest not using aminoglycosides for the treat-ment of infections unless no suitable, less nephro-toxic, therapeutic alternatives are available. (2A)We suggest that, in patients with normal kidney function in steady state, aminoglycosides a

28、re administered as a single dose daily rather thanmultiple-dose daily treatment regimens. (2B)We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A)We suggest monitoring aminoglycoside drug levels when treatment with single-d

29、aily dosing is used for more than 48 hours. (2C)We suggest using topical or local applications of aminoglycosides (e.g., respiratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. ( 2B),Prevention of aminoglycoside-,Prevention of aminoglycoside- anda

30、mphotericin-related AKI,We suggest using lipid formulations of ampho-tericin B rather than conventional formulations of amphotericin B. (2A)In the treatment of systemic mycoses or parasitic infections, we recommend using azole antifungal agents and/or the echinocandins rather than conventional ampho

31、tericin B, if equal therapeutic efficacy can be assumed.(1A),Prevention of aminoglycoside-,Other methods of prevention of AKIin the critically ill,We suggest that off-pump coronary artery bypass graft surgery not be selected solely for the purpose of reducing perioperative AKI or need for RRT. (2C)W

32、e suggest not using NAC to prevent AKI in critically ill patients with hypotension. (2D)We recommend not using oral or i.v. NAC for prevention of postsurgical AKI. (1A),CI-AKI:预防对比剂急性肾损害,Other methods of prevention of,Guideline 5：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,When to requ

33、est a renal referral？,Guideline 5：医疗资源合理分配多学科参与AKI指,Guideline 6：RRT模式的选择,建议个体化治疗！(1B),Kanagasundaram,2007,Guideline 6：RRT模式的选择建议个体化治疗！(,Guideline 7：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,Guideline 7：透析器和透析液的选择透析器：透析液,Guideline 8：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(1

34、B)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),Guideline 8：血管通路临时建立静脉-静脉通路(1,Guideline 8：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,Guideline 8：血管通路保护非优势侧的上肢血管(2,Guideline 9：体外抗凝,根据患者病情和RRT模式制定抗凝治疗方案(1

35、C)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),Guideline 9：体外抗凝根据患者病情和RRT模式制,Guideline 10：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

36、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),Guideline 10：RRT处方通过对RRT剂量的评估,CRRT剂量,We recommend delivering an effluent volume of 2025 ml/kg/h for CRRT in AKI (1A) . This will usually require a higher prescription of effluent volume. (Not Graded ),CRRT剂量We recommend delivering,急性肾损伤诊疗指南解读培训课件,临床适应症

37、,生化指标适应症,RRT开始指征 (1B),Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balanceexist. ( Not Graded),顽固性高钾血症6.5mmol/L血尿素氮27mmol/L,早期应用RRT治疗？,“早”：定义不统一BUN27mmol/L开始RRT，死亡风险翻倍,早期应用RRT治疗？“早”：定义不统一,危重病人伴有AKI时CRRT与IHD的利弊,CRRT与IHD相比具备以下优点：稳定的血流动力学，缓慢、连续性清除液体和溶质，溶质清除

38、率高; 持续稳定地控制氮质血症及电解质和水盐代谢;清除炎症介质，能够不断清除循环中存在的毒素和中小分子物质; 改善营养支持，保障营养补充及药物治疗,维持内环境稳定。缺点：花费大，机器昂贵，需要专业的医护团队，治疗期间不能外 出治疗、检查等。,危重病人伴有AKI时CRRT与IHD的利弊CRRT与IHD相,当AKI作为多脏器功能衰竭的一部分，需要提前进入肾脏替代治疗(1C)AKI患者临床症状改善并出现肾功能恢复的早期征象应适当推迟RRT(1D)过早行RRT带来的问题静脉血栓的形成导管相关性感染抗凝治疗导致的出血其他并发症,当AKI作为多脏器功能衰竭的一部分，需要提前进入肾脏替代治疗,CRRT与利尿

39、剂,We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. ( 2B),CRRT与利尿剂 We suggest not using,Typical setting of different RRT modalities for AKI (for 70-kg patient),We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients. (2B),Typical setting of different R,Guideline 12：对医学生的培养,Guideline 12：对医学生的培养AKI预防诊断治,Thanks！,Thanks！,