KDIGO急性腎損傷指南解讀

KDIGO急性腎損傷指南解讀KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryKidneyinter.Suppl.2012;2:1–138GRADE系統(tǒng)總推薦條目87條未分級26條29.9%2級39條63.9%1級22條36.1%1A:914.8%1B:1016.4%1C:34.9%2A:23.3%2B:1016.4%2C:2032.8%2D:711.5%內(nèi)容IntroductionandMethodologyAKIDefinitionPreventionandTreatmentofAKIContrast-inducedAKIDialysisInterventionsforTreatmentofAKI符合下列任何一條即可診斷

1.IncreaseinSCrby≥0.3mg/dl(≥26.5lmol/l)within48hours2.IncreaseinSCrto≥1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days3.Urinevolume<0.5ml/kg/hfor6hours.AKI診斷(NotGraded)StageSerumcreatinineUrineoutput11.5–1.9timesbaselineOR<0.5ml/kg/hfor≥0.3mg/dl(≥26.5mmol/l)increase6–12hours22.0–2.9timesbaseline<0.5ml/kg/hfor≥12hours33.0timesbaselineORIncreaseinserumcreatinineto<0.3ml/kg/hfor

≥4.0mg/dl(≥353.6mmol/l)≥24hoursORORInitiationofrenalreplacementtherapyAnuriafor≥12hoursOR,Inpatients<18years,decreaseineGFRto<35ml/minper1.73m2AKI分級(NotGraded)ThecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)SelectedcausesofAKIrequiringimmediatediagnosisandspecifictherapiesRecommendeddiagnostictestsDecreasedkidneyperfusionVolumestatusandurinarydiagnosticindicesAcuteglomerulonephritis,vasculitis,Urinesedimentexamination,interstitialnephritis,thromboticserologictestingandMicroangiopathyhematologictesting

UrinarytractobstructionKidneyultrasoundWerecommendthatpatientsbestratifiedforriskofAKIaccordingtotheirsusceptibilitiesandexposures.(1B)ManagepatientsaccordingtotheirsusceptibilitiesandexposurestoreducetheriskofAKI.(NotGraded)TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)ExposuresSusceptibilitiesSepsisDehydrationorvolumedepletionCriticalillnessAdvancedageCirculatoryshockFemalegenderBurnsBlackraceTraumaCKDCardiacsurgery(especiallyChronicdiseases(heart,lung,liver)withCPB)MajornoncardiacsurgeryDiabetesmellitusNephrotoxicdrugsCancerRadiocontrastagentsAnemiaPoisonousplantsandanimalsCausesofAKI:exposuresandsusceptibilitiesfornon-specificAKIEvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)MonitorpatientswithAKIwithmeasurementsofSCrandurineoutputtostagetheseverity,accordingtoRecommendation.(NotGraded)ManagepatientswithAKIaccordingtothestageandcause.(NotGraded)AKI時RRT治療時機(jī)InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.(NotGraded)Considerthebroaderclinicalcontext,thepresenceofconditionsthatcanbemodifiedwithRRT,andtrendsoflaboratorytests—ratherthansingleBUNandcreatininethresholdsalone—whenmakingthedecisiontostartRRT.(NotGraded)PotentialapplicationsforRRTApplicationsCommentsRenalreplacementThisisthetraditional,prevailingapproachbasedonutilizationofRRTwhenthereislittleornoresidualkidneyfunction.Life-threateningindicationsNotrialstovalidatethesecriteria.HyperkalemiaDialysisforhyperkalemiaiseffectiveinremovingpotassium;however,itrequiresfrequentmonitoringofpotassiumlevelsandadjustmentofconcurrentmedicalmanagementtopreventrelapses.AcidemiaMetabolicacidosisduetoAKIisoftenaggravatedbytheunderlyingcondition.CorrectionofmetabolicacidosiswithRRTintheseconditionsdependsontheunderlyingdiseaseprocess.PulmonaryedemaRRTisoftenutilizedtopreventtheneedforventilatorysupport;however,itisequallyimportanttomanagepulmonaryedemainventilatedpatients.Uremiccomplications(pericarditis,bleeding,etc.)IncontemporarypracticeitisraretowaittoinitiateRRTinAKIpatientsuntilthereareuremiccomplicationsPotentialapplicationsforRRTApplicationsCommentsNonemergentindicationsSolutecontrolBUNreflectsfactorsnotdirectlyassociatedwithkidneyfunction,suchascatabolicrateandvolumestatus.SCrisinfluencedbyage,race,musclemass,andcatabolicrate,andbychangesinitsvolumeofdistributionduetofluidadministrationorwithdrawal.FluidremovalFluidoverloadisanimportantdeterminantofthetimingofRRTinitiation.Correctionofacid-baseAbnormalitiesNostandardcriteriaforinitiatingdialysisexist.PotentialapplicationsforRRTApplicationsCommentsRenalsupportThisapproachisbasedontheutilizationofRRTtechniquesasanadjuncttoenhancekidneyfunction,modifyfluidbalance,andcontrolsolutelevels.VolumecontrolFluidoverloadisemergingasanimportantfactorassociatedwith,andpossiblycontributingto,adverseoutcomesinAKI.RecentstudieshaveshownpotentialbenefitsfromextracorporealfluidremovalinCHF.Intraoperativefluidremovalusingmodifiedultrafiltrationhasbeenshowntoimproveoutcomesinpediatriccardiacsurgerypatients.NutritionRestrictingvolumeadministrationinthesettingofoliguricAKImayresultinlimitednutritionalsupportandRRTallowsbetternutritionalsupplementation.DrugdeliveryRRTsupportcanenhancestheabilitytoadministerdrugswithoutconcernsaboutconcurrentfluidaccumulation.RegulationofPermissivehypercapnicacidosisinpatientswithlunginjurycanbecorrectedacid-basewithRRT,withoutinducingfluidoverloadandhypernatremia.andelectrolytestatusSoluteChangesinsoluteburdenshouldbeanticipated(e.g.,tumorlysismodulationsyndrome).Althoughcurrentevidenceisunclear,studiesareongoingtoassesstheefficacyofRRTforcytokinemanipulationinsepsis.

AKI時停用RRT指征DiscontinueRRTwhenitisnolongerrequired,eitherbecauseintrinsickidneyfunctionhasrecoveredtothepointthatitisadequatetomeetpatientneeds,orbecauseRRTisnolongerconsistentwiththegoalsofcare.(NotGraded)Wesuggestnotusingdiureticstoenhancekidneyfunctionrecovery,ortoreducethedurationorfrequencyofRRT.(2B)抗凝治療InapatientwithAKIrequiringRRT,basethedecisiontouseanticoagulationforRRTonassessmentofthepatient’spotentialrisksandbenefitsfromanticoagulation.(NotGraded)WerecommendusinganticoagulationduringRRTinAKIifapatientdoesnothaveanincreasedbleedingriskorimpairedcoagulationandisnotalreadyreceivingsystemicanticoagulation.(1B)Forpatientswithoutanincreasedbleedingriskorimpairedcoagulationandnotalreadyreceivingeffectivesystemicanticoagulation,wesuggestthefollowing:ForanticoagulationinintermittentRRT,werecommendusingeitherunfractionatedorlow-molecular-weightheparin,ratherthanotheranticoagulants.(1C)ForanticoagulationinCRRT,wesuggestusingregionalcitrateanticoagulationratherthanheparininpatientswhodonothavecontraindicationsforcitrate.(2B)ForanticoagulationduringCRRTinpatientswhohavecontraindicationsforcitrate,wesuggestusingeitherunfractionatedorlow-molecular-weightheparin,ratherthanotheranticoagulants.(2C)抗凝治療Forpatientswithincreasedbleedingriskwhoarenotreceivinganticoagulation,wesuggestthefollowingforanticoagulationduringRRT:Wesuggestusingregionalcitrateanticoagulation,ratherthannoanticoagulation,duringCRRTinapatientwithoutcontraindicationsforcitrate.(2C)WesuggestavoidingregionalheparinizationduringCRRTinapatientwithincreasedriskofbleeding.(2C)抗凝治療Inapatientwithheparin-inducedthrombocytopenia(HIT),allheparinmustbestoppedandwerecommendusingdirectthrombininhibitors(suchasargatroban)orFactorXainhibitors(suchasdanaparoidorfondaparinux)ratherthanotherornoanticoagulationduringRRT.(1A)InapatientwithHITwhodoesnothavesevereliverfailure,wesuggestusingargatrobanratherthanotherthrombinorFactorXainhibitorsduringRRT.(2C)抗凝治療血管通路WesuggestinitiatingRRTinpatientswithAKIviaanuncuffednontunneleddialysiscatheter,ratherthanatunneledcatheter.(2D)WhenchoosingaveinforinsertionofadialysiscatheterinpatientswithAKI,considerthesepreferences(NotGraded):*Firstchoice:rightjugularvein;*Secondchoice:femoralvein;*Thirdchoice:leftjugularvein;*Lastchoice:subclavianveinwithpreferenceforthedominantside.Werecommendusingultrasoundguidancefordialysiscatheterinsertion.(1A)Werecommendobtainingachestradiographpromptlyafterplacementandbeforefirstuseofaninternaljugularorsubclaviandialysiscatheter.(1B)WesuggestnotusingtopicalantibioticsovertheskininsertionsiteofanontunneleddialysiscatheterinICUpatientswithAKIrequiringRRT.(2C)Wesuggestnotusingantibioticlocksforpreventionofcatheter-relatedinfectionsofnontunneleddialysiscathetersinAKIrequiringRRT.(2C)血管通路濾器選擇WesuggesttousedialyzerswithabiocompatiblemembraneforIHDandCRRTinpatientswithAKI.(2C)RRT模式選擇UsecontinuousandintermittentRRTascomplementarytherapiesinAKIpatients.(NotGraded)WesuggestusingCRRT,ratherthanstandardintermittentRRT,forhemodynamicallyunstablepatients.(2B)WesuggestusingCRRT,ratherthanintermittentRRT,forAKIpatientswithacutebraininjuryorothercausesofincreasedintracranialpressureorgeneralizedbrainedema.(2B)TypicalsettingofdifferentRRTmodalitiesforAKI(for70-kgpatient)Theoretical