急性腎損傷診療指南解讀教材課件

急性腎損傷診療指南解讀急性腎損傷診療指南解讀1（優(yōu)選）急性腎損傷診療指南解讀版（優(yōu)選）急性腎損傷診療指南解讀版2AboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryAboutAKIguidelineADQI：2002,3AKI流行病學(xué)現(xiàn)狀患病率：1%（社區(qū)）~7.1%（醫(yī)院）人群發(fā)病率：486~630pmp/yAKI需要RRT發(fā)病率：22~203pmp/y醫(yī)院獲得AKI死亡率：10~80%合并多臟器功能衰竭死亡率：>50%需要RRT治療者死亡率：高達80%AKI流行病學(xué)現(xiàn)狀患病率：1%（社區(qū)）~7.1%（醫(yī)院）4指南推薦強度指南推薦強度5指南推薦強度指南推薦強度6Guideline1：AKI的定義與分期符合以下情況之一者即可被診斷為AKI：①

48小時內(nèi)Scr升高超過26.5μmol/L(0.3

mg/dl)；②

Scr

升高超過基線1.5倍—確認或推測7天內(nèi)發(fā)生；③

尿量＜0.5

ml/（kg·h），且持續(xù)6小時以上。單用尿量改變作為判斷標(biāo)準時，需要除外尿路梗阻及其它導(dǎo)致尿量減少的原因采用KDIGO推薦的定義和分期標(biāo)準Guideline1：AKI的定義與分期符合以下情況之一者7InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.采用KDIGO推薦的定義和分期標(biāo)準Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.監(jiān)測乳酸和堿剩余水平controlonall-causemortality.AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.discontinuationofRRTinAKIisnotevident.Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.NACforpreventionofpostsurgicalAKI.5倍—確認或推測7天內(nèi)發(fā)生；具有高出血風(fēng)險的患者可采取無抗凝劑、鹽水沖洗的方法，但引起超濾量增加，透析效率下降及增加了透析膜破裂的風(fēng)險(2C)慎用高分子量羥乙基淀粉1mg/kg/min,forthepreventionortreatmentofAKI.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.1詳細的病史采集和體格檢查有助于AKI病因的判斷(1A)GFR<60ml/min/1.2評估容量狀態(tài)后適當(dāng)補液(1B)AKI分期標(biāo)準指南推薦血清肌酐和尿量仍然作為AKI最好的標(biāo)志物(1B)InitiateRRTemergentlywhenl8RIFLE分級2002年急性透析質(zhì)量倡議組(ADQI)制定了ARF的RIFLE分級診斷標(biāo)準。BellomoR,etal.CritCare2004;8:R204-R212RIFLE分級2002年急性透析質(zhì)量倡議組(ADQI)制定9ConceptualmodelforAKIConceptualmodelforAKI10Guideline2：臨床評估2.1詳細的病史采集和體格檢查有助于AKI病因的判斷(1A)2.224小時之內(nèi)進行基本的檢查，包括尿液分析和泌尿系超聲(懷疑有尿路梗阻者)(1A)Guideline2：臨床評估2.1詳細的病史采集和體格11Chapter2.2:RiskassessmentChapter2.2:Riskassessment12Chapter2.2:RiskassessmentChapter2.2:Riskassessment13AKIisdefinedasanyofthefollowing(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)

DefinitionandstagingofAKIAKIisdefinedasanyofthe14OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.OverviewofAKI,CKD,andAKD.15AKD

acutekidneydiseasesanddisorder符合以下任何一項AKI,符合AKI定義3個月內(nèi)在原來基礎(chǔ)上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3個月腎損傷<3個月AKD

acutekidneydiseasesand16AKI/CKD/AKD腎功能改變腎臟結(jié)構(gòu)改變AKI7天內(nèi)血肌酐升高50%2天內(nèi)血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3個月>3個月AKDAKI3個月內(nèi)在原來基礎(chǔ)上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3個月<3個月NKD無異常AKI/CKD/AKD腎功能改變腎臟結(jié)構(gòu)改變AKI7天內(nèi)血肌17Guideline3：PreventionandTreatmentofAKI3.1評估危險因素(1B)年齡>75歲CKD(eGFR<60ml/min/1.73m2心力衰竭動脈粥樣硬化性周圍血管病變肝臟疾病糖尿病腎毒性藥物的使用低血容量感染3.2評估容量狀態(tài)后適當(dāng)補液(1B)HIGHRISKGuideline3：PreventionandTre183.3造影劑腎病3.4繼發(fā)于橫紋肌溶解的AKI給予0.9%氯化鈉和碳酸氫鈉擴容(1B)對具CI-AKI高風(fēng)險者：建議采用等滲或低滲造影劑建議口服或靜脈使用N

-乙酰半胱氨酸（NAC）及等滲晶體預(yù)防CI-AKI推薦使用等滲氯化鈉或碳酸氫鈉靜脈擴容以預(yù)防CI-AKI

3.3造影劑腎病3.4繼發(fā)于橫紋肌溶解的AKI對具CI-AK19Guideline4：AKI的治療一般治療(1A)Guideline4：AKI的治療一般治療(1A)20Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIStage-basedmanagementofAKIC21GFR<60ml/min/1.Werecommendnotusinglow-dosedopaminetopreventortreatAKI.discontinuationofRRTinAKIisnotevident.controlonneedforRRT.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMeta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CritCare2004;8:R204-R2125g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.BMJ2006;333(7565):420-4255

ml/（kg·h），且持續(xù)6小時以上。Thiswillusuallyrequireahigherprescriptionofeffluentvolume.2評估容量狀態(tài)后適當(dāng)補液(1B)Effectoffurosemidevs.監(jiān)測乳酸和堿剩余水平MehtaRL,PascualMT,SorokoSetal.arenalreferral？FriedrichJO,AdhikariN,HerridgeMS.discontinuationofRRTinAKIisnotevident.根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(ANP)toprevent(2C)ortreat(2B)AKI補液治療Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)GFR<60ml/min/1.補液治療Intheabse22補液治療：低血容量者：重復(fù)小劑量補液(250ml晶體液/膠體液）

密切監(jiān)測CVP和尿量監(jiān)測乳酸和堿剩余水平嚴重膿毒血癥者：慎用高分子量羥乙基淀粉

補液治療：23藥物治療(1B)多臟器功能衰竭藥代動力學(xué)改變（分布容積、清除、與蛋白結(jié)合）需要調(diào)整藥物劑量藥物治療(1B)多臟器功能衰竭24目前無特殊的藥物用于治療繼發(fā)于低灌注損傷/膿毒血癥的AKI(1B)袢利尿劑againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425目前無特殊的藥物用于治療繼發(fā)于低灌注損傷/膿毒血癥的AKI25Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)Chapter3.4:Theuseofdiuret26Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr27Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr28AnnInternMed2005;142:510-5242評估容量狀態(tài)后適當(dāng)補液(1B)醫(yī)院獲得AKI死亡率：10~80%導(dǎo)管僅限于RRT治療時使用(1D)以預(yù)防感染(NotGraded)7天內(nèi)血肌酐升高50%Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.急性腎損傷診療指南解讀危重病人伴有AKI時CRRT與IHD的利弊WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.abeneficialroleforloopdiureticsinfacilitating根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；MehtaRL,PascualMT,SorokoSetal.腎臟科與ICU醫(yī)生協(xié)作腎臟科與ICU醫(yī)生協(xié)作Werecommendnotusingoralori.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.ADQI：2002,RIFLETheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI.abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident.AnnInternMed2005;142:510-29甘露醇mannitolisnotscientificallyjustifiedinthepreventionofAKI.甘露醇mannitolisnotscientifica30Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWerecommendnotusinglow-dosedopaminetopreventortreatAKI.（1A）Wesuggestnotusingfenoldopam（非諾多巴）topreventortreatAKI.(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKIVasodilatortherapy:dopamine,31Effectoflow-dosedopamineonmortality.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；Effectoflow-dosedopamineon32多巴胺---不建議FriedrichJO,AdhikariN,HerridgeMS.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510-524降低腎灌注(Lauschke,KidneyInt2006)導(dǎo)致心律失常(Schenarts,CurrentSurgery2006)加重心肌、腸道缺血缺氧(Schenarts,CurrentSurgery2006)非諾多巴---不建議選擇性多巴胺A1受體激動劑，在降低全身血管阻力的同時增加腎血流量RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.1mg/kg/min,forthepreventionortreatmentofAKI.ThereisapossibilitythatANPmightbeeffectiveifitisgivenatalowerdose(0.01–0.05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；多巴胺---不建議FriedrichJO,Adhikar33GlycemiccontrolandnutritionalsupportIncriticallyillpatients,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）Glycemiccontrolandnutrition342，或者進行每日透析(1B)由經(jīng)驗豐富的醫(yī)生負責(zé)置管(1A)2002年急性透析質(zhì)量倡議組(ADQI)制定了ARF的RIFLE分級診斷標(biāo)準。Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Guideline2：臨床評估采用KDIGO推薦的定義和分期標(biāo)準AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；AboutAKIguidelineGFR<60ml/min/1.(NotGraded)discontinuationofRRTinAKIisnotevident.保護非優(yōu)勢側(cè)的上肢血管(2C)腎臟科與ICU醫(yī)生協(xié)作建議口服或靜脈使用N

-乙酰半胱氨酸（NAC）及等滲晶體預(yù)防CI-AKIWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.難以糾正的容量負荷過重0g/kg/dofproteininnoncatabolicAKIpatientswithoutneedfordialysis(2D),1.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.GrowthfactorinterventionWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.（1B）humanIGF-1：重組人胰島素樣生長因子12，或者進行每日透析(1B)Growthfactorin35Preventionofaminoglycoside-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-36Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB.(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.(1A)Preventionofaminoglycoside-37OthermethodsofpreventionofAKI

inthecriticallyillWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT.(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.(2D)Werecommendnotusingoralori.v.NACforpreventionofpostsurgicalAKI.(1A)CI-AKI:預(yù)防對比劑急性腎損害Othermethodsofpreventionof38Guideline5：醫(yī)療資源合理分配多學(xué)科參與AKI指南制定腎科醫(yī)生會診提供專科意見合理的轉(zhuǎn)診方案密切監(jiān)護治療腎臟科與ICU醫(yī)生協(xié)作Whentorequestarenalreferral？Guideline5：醫(yī)療資源合理分配多學(xué)科參與AKI指39Guideline6：RRT模式的選擇建議個體化治療！(1B)Kanagasundaram,2007Guideline6：RRT模式的選擇建議個體化治療！(40Guideline7：

透析器和透析液的選擇透析器：合成膜透析器(1B)改良纖維素膜透析器(1B)透析液：首選碳酸氫鈉透析液/置換液(1C)透析液微生物的控制Guideline7：

透析器和透析液的選擇透析器：透析液41Guideline8：血管通路臨時建立靜脈-靜脈通路(1A)選擇足夠長度的透析導(dǎo)管以降低再循環(huán)率(1B)置管部位和導(dǎo)管類型需根據(jù)患者的病情選擇(2C)由經(jīng)驗豐富的醫(yī)生負責(zé)置管(1A)實時超聲導(dǎo)引有助于置管(1D)對有進展至CKD4-5期風(fēng)險的患者，盡量避免行鎖骨下靜脈置管，保護患者的血管資源(1D)Guideline8：血管通路臨時建立靜脈-靜脈通路(142Guideline8：血管通路保護非優(yōu)勢側(cè)的上肢血管(2C)定期更換臨時導(dǎo)管以降低感染的風(fēng)險(1C)頸內(nèi)靜脈：3周股靜脈：1周>3周：建議用皮下隧道導(dǎo)管導(dǎo)管僅限于RRT治療時使用(1D)以預(yù)防感染Guideline8：血管通路保護非優(yōu)勢側(cè)的上肢血管(243Guideline9：體外抗凝根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)推薦枸櫞酸局部抗凝降低出血風(fēng)險(2C)具有出血風(fēng)險的患者可選擇前列環(huán)素抗凝，但會引起血流動力學(xué)不穩(wěn)定(2C)具有高出血風(fēng)險的患者可采取無抗凝劑、鹽水沖洗的方法，但引起超濾量增加，透析效率下降及增加了透析膜破裂的風(fēng)險(2C)Guideline9：體外抗凝根據(jù)患者病情和RRT模式制44難以糾正的電解質(zhì)紊亂:低鈉血癥、高鈉血癥或高鈣血癥Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.5

ml/（kg·h），且持續(xù)6小時以上。慎用高分子量羥乙基淀粉Werecommendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours.GlycemiccontrolandnutritionalsupportWesuggestnotusingaminoglycosidesforthetreat-mentofinfectionsunlessnosuitable,lessnephro-toxic,therapeuticalternativesareavailable.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;(NotGraded)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.Guideline2：臨床評估(NotGraded)ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Werecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.>3周：建議用皮下隧道導(dǎo)管ADQI：2002,RIFLEAKIguidelineforAKI:201105mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；AKIguidline—KDIGO2012Guideline10：RRT處方通過對RRT劑量的評估確保透析充分性(1A)每次(IHD）或每日（CRRT)評估透析劑量及充分性(1A)推薦伴有多器官功能衰竭的AKI患者行CRRT，后稀釋法超濾率>25ml/kg/hr。前稀釋法的持續(xù)性血液濾過相應(yīng)的上調(diào)超濾率(1A)伴有多器官功能衰竭的AKI患者行間歇性血液透析治療治療時，必須達到單次透析URR>65%或eKt/V>1.2，或者進行每日透析(1B)難以糾正的電解質(zhì)紊亂:低鈉血癥、高鈉血癥或高鈣血癥Guide45CRRT劑量Werecommenddeliveringaneffluentvolumeof20–25ml/kg/hforCRRTinAKI(1A).Thiswillusuallyrequireahigherprescriptionofeffluentvolume.(NotGraded)CRRT劑量Werecommenddelivering46急性腎損傷診療指南解讀教材課件47頑固性高鉀血癥>6.5mmol/L血尿素氮>27mmol/L難以糾正的代謝性酸中毒PH<7.15難以糾正的電解質(zhì)紊亂:低鈉血癥、高鈉血癥或高鈣血癥腫瘤溶解綜合癥伴有的高尿酸血癥和高磷酸鹽血癥尿素循環(huán)障礙和有機酸尿癥導(dǎo)致的高氨血癥和甲基丙二酸血癥尿量<0.3ml/kg/h持續(xù)24h或者無尿12hAKI伴有多器官功能衰竭難以糾正的容量負荷過重累及終末器官：心包炎，腦病，神經(jīng)病變，肌病和尿毒癥出血需要輸注血制品和靜脈營養(yǎng)重度中毒或藥物過量嚴重的低體溫或高體溫臨床適應(yīng)癥生化指標(biāo)適應(yīng)癥RRT開始指征(1B)InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.(NotGraded)頑固性高鉀血癥>6.5mmol/L血尿素氮>27mmol/L48早期應(yīng)用RRT治療？“早”：定義不統(tǒng)一BUN<21.5mmol/L（創(chuàng)傷后），或者尿量<100ml/8小時（心臟手術(shù)后）達到下列指標(biāo)12小時內(nèi)進行RRT：尿量<30/h持續(xù)6小時Ccr<20ml/minBUN>27mmol/L開始RRT，死亡風(fēng)險翻倍早期應(yīng)用RRT治療？“早”：定義不統(tǒng)一49DefinitionandstagingofAKIGuideline2：臨床評估Effectoffurosemidevs.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CI-AKI:預(yù)防對比劑急性腎損害(NotGraded)CRRT與IHD相比具備以下優(yōu)點：abeneficialroleforloopdiureticsinfacilitatingWesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)密切監(jiān)測CVP和尿量9%氯化鈉和碳酸氫鈉擴容(1B)KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMehtaRL,PascualMT,SorokoSetal.慎用高分子量羥乙基淀粉discontinuationofRRTinAKIisnotevident.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.難以糾正的容量負荷過重2評估容量狀態(tài)后適當(dāng)補液(1B)1mg/kg/min,forthepreventionortreatmentofAKI.(NotGraded)BMJ2006;333(7565):420-425危重病人伴有AKI時CRRT與IHD的利弊CRRT與IHD相比具備以下優(yōu)點：①穩(wěn)定的血流動力學(xué)，緩慢、連續(xù)性清除液體和溶質(zhì)，②溶質(zhì)清除率高;③持續(xù)穩(wěn)定地控制氮質(zhì)血癥及電解質(zhì)和水鹽代謝;④清除炎癥介質(zhì)，能夠不斷清除循環(huán)中存在的毒素和中小分子物質(zhì);⑤改善營養(yǎng)支持，保障營養(yǎng)補充及藥物治療,維持內(nèi)環(huán)境穩(wěn)定。缺點：花費大，機器昂貴，需要專業(yè)的醫(yī)護團隊，治療期間不能外出治療、檢查等。DefinitionandstagingofAKI危50急性腎損傷診療指南解讀急性腎損傷診療指南解讀51（優(yōu)選）急性腎損傷診療指南解讀版（優(yōu)選）急性腎損傷診療指南解讀版52AboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryAboutAKIguidelineADQI：2002,53AKI流行病學(xué)現(xiàn)狀患病率：1%（社區(qū)）~7.1%（醫(yī)院）人群發(fā)病率：486~630pmp/yAKI需要RRT發(fā)病率：22~203pmp/y醫(yī)院獲得AKI死亡率：10~80%合并多臟器功能衰竭死亡率：>50%需要RRT治療者死亡率：高達80%AKI流行病學(xué)現(xiàn)狀患病率：1%（社區(qū)）~7.1%（醫(yī)院）54指南推薦強度指南推薦強度55指南推薦強度指南推薦強度56Guideline1：AKI的定義與分期符合以下情況之一者即可被診斷為AKI：①

48小時內(nèi)Scr升高超過26.5μmol/L(0.3

mg/dl)；②

Scr

升高超過基線1.5倍—確認或推測7天內(nèi)發(fā)生；③

尿量＜0.5

ml/（kg·h），且持續(xù)6小時以上。單用尿量改變作為判斷標(biāo)準時，需要除外尿路梗阻及其它導(dǎo)致尿量減少的原因采用KDIGO推薦的定義和分期標(biāo)準Guideline1：AKI的定義與分期符合以下情況之一者57InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.采用KDIGO推薦的定義和分期標(biāo)準Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.監(jiān)測乳酸和堿剩余水平controlonall-causemortality.AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.discontinuationofRRTinAKIisnotevident.Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.NACforpreventionofpostsurgicalAKI.5倍—確認或推測7天內(nèi)發(fā)生；具有高出血風(fēng)險的患者可采取無抗凝劑、鹽水沖洗的方法，但引起超濾量增加，透析效率下降及增加了透析膜破裂的風(fēng)險(2C)慎用高分子量羥乙基淀粉1mg/kg/min,forthepreventionortreatmentofAKI.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.1詳細的病史采集和體格檢查有助于AKI病因的判斷(1A)GFR<60ml/min/1.2評估容量狀態(tài)后適當(dāng)補液(1B)AKI分期標(biāo)準指南推薦血清肌酐和尿量仍然作為AKI最好的標(biāo)志物(1B)InitiateRRTemergentlywhenl58RIFLE分級2002年急性透析質(zhì)量倡議組(ADQI)制定了ARF的RIFLE分級診斷標(biāo)準。BellomoR,etal.CritCare2004;8:R204-R212RIFLE分級2002年急性透析質(zhì)量倡議組(ADQI)制定59ConceptualmodelforAKIConceptualmodelforAKI60Guideline2：臨床評估2.1詳細的病史采集和體格檢查有助于AKI病因的判斷(1A)2.224小時之內(nèi)進行基本的檢查，包括尿液分析和泌尿系超聲(懷疑有尿路梗阻者)(1A)Guideline2：臨床評估2.1詳細的病史采集和體格61Chapter2.2:RiskassessmentChapter2.2:Riskassessment62Chapter2.2:RiskassessmentChapter2.2:Riskassessment63AKIisdefinedasanyofthefollowing(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)

DefinitionandstagingofAKIAKIisdefinedasanyofthe64OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.OverviewofAKI,CKD,andAKD.65AKD

acutekidneydiseasesanddisorder符合以下任何一項AKI,符合AKI定義3個月內(nèi)在原來基礎(chǔ)上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3個月腎損傷<3個月AKD

acutekidneydiseasesand66AKI/CKD/AKD腎功能改變腎臟結(jié)構(gòu)改變AKI7天內(nèi)血肌酐升高50%2天內(nèi)血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3個月>3個月AKDAKI3個月內(nèi)在原來基礎(chǔ)上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3個月<3個月NKD無異常AKI/CKD/AKD腎功能改變腎臟結(jié)構(gòu)改變AKI7天內(nèi)血肌67Guideline3：PreventionandTreatmentofAKI3.1評估危險因素(1B)年齡>75歲CKD(eGFR<60ml/min/1.73m2心力衰竭動脈粥樣硬化性周圍血管病變肝臟疾病糖尿病腎毒性藥物的使用低血容量感染3.2評估容量狀態(tài)后適當(dāng)補液(1B)HIGHRISKGuideline3：PreventionandTre683.3造影劑腎病3.4繼發(fā)于橫紋肌溶解的AKI給予0.9%氯化鈉和碳酸氫鈉擴容(1B)對具CI-AKI高風(fēng)險者：建議采用等滲或低滲造影劑建議口服或靜脈使用N

-乙酰半胱氨酸（NAC）及等滲晶體預(yù)防CI-AKI推薦使用等滲氯化鈉或碳酸氫鈉靜脈擴容以預(yù)防CI-AKI

3.3造影劑腎病3.4繼發(fā)于橫紋肌溶解的AKI對具CI-AK69Guideline4：AKI的治療一般治療(1A)Guideline4：AKI的治療一般治療(1A)70Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIStage-basedmanagementofAKIC71GFR<60ml/min/1.Werecommendnotusinglow-dosedopaminetopreventortreatAKI.discontinuationofRRTinAKIisnotevident.controlonneedforRRT.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMeta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CritCare2004;8:R204-R2125g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.BMJ2006;333(7565):420-4255

ml/（kg·h），且持續(xù)6小時以上。Thiswillusuallyrequireahigherprescriptionofeffluentvolume.2評估容量狀態(tài)后適當(dāng)補液(1B)Effectoffurosemidevs.監(jiān)測乳酸和堿剩余水平MehtaRL,PascualMT,SorokoSetal.arenalreferral？FriedrichJO,AdhikariN,HerridgeMS.discontinuationofRRTinAKIisnotevident.根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(ANP)toprevent(2C)ortreat(2B)AKI補液治療Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)GFR<60ml/min/1.補液治療Intheabse72補液治療：低血容量者：重復(fù)小劑量補液(250ml晶體液/膠體液）

密切監(jiān)測CVP和尿量監(jiān)測乳酸和堿剩余水平嚴重膿毒血癥者：慎用高分子量羥乙基淀粉

補液治療：73藥物治療(1B)多臟器功能衰竭藥代動力學(xué)改變（分布容積、清除、與蛋白結(jié)合）需要調(diào)整藥物劑量藥物治療(1B)多臟器功能衰竭74目前無特殊的藥物用于治療繼發(fā)于低灌注損傷/膿毒血癥的AKI(1B)袢利尿劑againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425目前無特殊的藥物用于治療繼發(fā)于低灌注損傷/膿毒血癥的AKI75Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)Chapter3.4:Theuseofdiuret76Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr77Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr78AnnInternMed2005;142:510-5242評估容量狀態(tài)后適當(dāng)補液(1B)醫(yī)院獲得AKI死亡率：10~80%導(dǎo)管僅限于RRT治療時使用(1D)以預(yù)防感染(NotGraded)7天內(nèi)血肌酐升高50%Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.急性腎損傷診療指南解讀危重病人伴有AKI時CRRT與IHD的利弊WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.abeneficialroleforloopdiureticsinfacilitating根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；MehtaRL,PascualMT,SorokoSetal.腎臟科與ICU醫(yī)生協(xié)作腎臟科與ICU醫(yī)生協(xié)作Werecommendnotusingoralori.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.ADQI：2002,RIFLETheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestth