crrt影響aki殘余腎功能嗎？課件

CRRT影響AKI殘余腎功能嗎？OutlineAKI的流行病學(xué)殘余腎功能的概念及臨床意義CRRT對(duì)殘余腎功能的影響及可能機(jī)制小結(jié)ARF的現(xiàn)狀-發(fā)生率逐年增加Community-basedincidencerates(per100000person-years)ofnondialysisrequiringARFbycalendaryearKidneyInt,2007;72(2):208–212Community-basedincidencerates(per100000person-years)ofdialysis-requiringARFbycalendaryearProspectiveobservationalstudySeptember2000toDecember2001at54hospitalsin23countriesOf29269criticallyillpatientsadmittedduringthestudyperiod,1738(5.7%;95%CI5.5%-6.0%)hadARFduringtheirICUstay,including1260whoweretreatedwithRRTJAMA.2005;294:813-818ThecriteriaforARF：少尿(12小時(shí)<200ml)或/和血尿素氮高于84mg/dL(30mmol/L)MortalitywithacutekidneyfailureJAMA.2005;294:813-818Overallhospitalmortalitywas60.3%RIFLEcriteria:incidenceandassociatedmortalityCriticalCare2006,10:R735383criticallyillpatientsin7ICUs,AKIoccurredin67%ofpatientsMortality:hazardratioof2.7EpidemiologyofAKIBloodPurif2011;31:159–171MulticenterItalianStudyRIFLE-BasedDataOutlineAKI的流行病學(xué)殘余腎功能的概念及臨床意義CRRT對(duì)殘余腎功能的影響及可能機(jī)制小結(jié)殘余腎功能(ResidualrenalfunctionRRF)定義：是指腎臟受到損傷后健存腎單位的殘留功能，包括清除毒素、調(diào)節(jié)水電解質(zhì)和酸堿平衡以及多種內(nèi)分泌功能殘余腎功能與AKI長(zhǎng)期預(yù)后正相關(guān)IntensityofRenalSupport不改善AKI病死率NEnglJMed2008;359:7-20.NEnglJMed2009;361:1627-38.Onceanorganisinjured

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CriticalCare2012,16:317OutlineAKI的流行病學(xué)殘余腎功能的概念及臨床意義CRRT對(duì)殘余腎功能的影響及可能機(jī)制小結(jié)CRRT特點(diǎn)穩(wěn)定的血流動(dòng)力學(xué)持續(xù)穩(wěn)定的控制氮質(zhì)血癥和水電/酸堿平衡能夠不斷清除循環(huán)中的毒素或中分子物質(zhì)按需提供營(yíng)養(yǎng)補(bǔ)充和藥物治療CRRTvsIRRTIHDPDCRRTHemodynamicstability…+++Osmopressurestability…++++Fluidremoval++++++Correctionofacidosis++++++UnlimitedPN/EN……++ClearancesSmallsolutes(<500d)++++++Largesolutes(>500d)…++++Mediatorremoval……++?Accessmorbidity++++Anticoagulationneeds+…+Simplicity++++++ComparedtoIRRT,CRRTcanhelptoraiseMAPTheCochraneLibrary2008,Issue3CRRTdecreasestherequiringofpressorTheCochraneLibrary2008,Issue3CRRTisassociatedwithmorestablehaemodynamicsthanIRRTRetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,19992ICUinCanada.N=261CRRTIHDPAPACHEII2725.10.10BaselineSCr1361800.002MAPBeforeRRT74.787.2<0.001HospMortality71.9%42.2%<0.01Renalrecoveryinhosp80.0%62.5%0.06DurationofRRT14.7d14.5d0.91Costperweek(Can$)3486-51171341Survivor(Costpery)No-RRTRRT$11,192$73,273CRRT對(duì)ARF腎功能恢復(fù)的影響

－CRRT促進(jìn)腎功能恢復(fù)CritCareMed2003;31:449–455CRRT：腎功能恢復(fù)1218patientsforARFin54ICUin23countriesIntJArtifOrgans2007;30(4):281-292腎功能恢復(fù)CRRT能促進(jìn)腎功能恢復(fù)DesignRetrospectivecohortstudy32SwedishICUs2,202patientswithARF(excludeESRD)IntensiveCareMed.2007,33:773–780VeryhighrateofintradialytichypotensionintheIHDgroup–comparedtoCRRT/SLEDtreatments:TwiceasmanyIHDtreatmentsrequiredincreasedvasopressorsupportSixtimesasmanyIHDtreatmentshadtobestoppedRenalrecoveryratewaslowerthanexpected(~50%at28days)–possiblyrelatedtohypotensionduringIHDATNTrial:ImportantResultsDebateofrecoveryofrenalfunction

--ResultsofMetaanalysisMetaanalysisshowsnodifferenceinmortalityandchronicdialysisdependenceofpatientswithARFamongCRRT,IRRTorSLEDJAMA.2008;299(7):793-805SafetyCRRTRequirecontinuousanticoagulationTimeislongerIRRTRapidfluidandsoluteremovelBleedingDepletionofnutrientsInfectionHypotensionArrhythmiaHypothermiaismorefrequentduringCRRT,othercomplicationsaresimilarLancet2006;368:379–85OutlineAKI的流行病學(xué)殘余