CRRT的規(guī)范化治療

1、1會計學(xué)CRRT的規(guī)范化治療的規(guī)范化治療血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）CRRT CRRT is any extracorpreal blood purificattion therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours/day 所謂CRRT也就是指所有每天24小時或接近24小時的緩慢、連續(xù)清除水和溶質(zhì)的治療方法。血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）

2、總 結(jié)RIFLE Criteria for Acute Renal DysfunctionRiskInjuryFailureLossESRDIncreased creatinine x1.5 or GFR decrease 25%End Stage Renal Disease GFR Criteria*Urine Output CriteriaUO .3ml/kg/hx 24 hr or Anuria x 12 hrsUO .5ml/kg/hx 12 hrUO 50% Increase creatinine x3or GFR dec 75%or creatinine 4mg/dl(Acute

3、rise of 0.5 mg/dl) HighSensitivityHighSpecificityPersistent ARF* = complete loss of renal function 4 weeks Oliguria“Acute on Chronic” DiseaseBaseline0.5 (44)1.0 (88)1.5 (133)2.0 (177)2.5 (221)3.0 (265)Risk0.75 (66)1.5 (133)2.3 (200)3.0 (265)3.8 (332)-Injury1.0 (88) 2.0 (177)3.0 (265)-Failure1.5 (133

4、)3.0 (265)4.0 (350)4.0 (350)4.0 (350)4.0 (350)Creatinine is expressed in mg/dL and (mcmol/L). AKIN分層標(biāo)準(zhǔn) Stage Serum creatinine criteria Urine output criteria 1 Increase in serum creatinine of more than or equal to 0.3 mg/dl Less than 0.5 ml/kg per ( 26.4 mol/l) or increase to hour for more than 6 hou

5、rs more than or equal to 150% to 200% (1.5- to 2-fold) from baseline 2 Increase in serum creatinine to Less than 0.5 ml/kg per more than200% to 300% hour for more than 12hours ( 2- to 3-fold) frombaseline 3 Increase in serum creatinine to Less than 0.3 ml/kg per more than300% ( 3-fold) from hour for

6、 24 hours or baseline(or serumcreatinine of anuria for 12 hours more than or equato 4.0 mg/dl 354 mol/l with an acute increaseof at least 0.5 mg/dl 44 mol/l)血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）Acute renal failureAsymptomatic,nonoliguric,adequate nutrition possible(Non)oliguric,haemodynamically stabl

7、e;life-threathening hyperkalaemia(Non)oliguric,haemodynamically unstableHigh risk of bleedingNo high riskExpectative(Increasing) uraemiaIHD#UnstableCitrate-CRRTCRRTStableAlgorithm for the dialytic treatment of acute renal failure according to circumstancesIHD = intermittent haemodialysis, CRRT = con

8、tinuous renal replacement therapy. Delay initiation of dialytic treatment to maximise the odds of native renal recovery, # if no citrate-protocol for CRRT, heparin-free IHD may be used as alternative treatment.非腎臟疾病 非腎臟疾病包括多器官功能障礙綜合征（MODS）、膿毒血癥或敗血癥性休克、急性呼吸窘迫綜合征（ARDS）、擠壓綜合征、乳酸酸中毒、急性重癥胰腺炎、心肺體外循環(huán)手術(shù)、慢性心

9、力衰竭、肝性腦病、藥物或毒物中毒、嚴(yán)重液體潴留、需要大量補(bǔ)液、電解質(zhì)和酸堿代謝紊亂、腫瘤溶解綜合征、過高熱等血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）Bellomo and Ronco Crit Care 2000, 4:339345Any one of these indications constitutes sufficient grounds for considering the initiation of CRRT. Two of the above criteria make CRRT highly desirable. Combined disor

10、ders suggest the initiation of CRRT even before some of the above-mentioned limits have been reached. *IHD removes potassium more efficiently than CRRT.However, if CRRT is started early enough, hyperkalaemia is easily controlled. For example, a fulminant liver failure patient with adult respiratory

11、distress syndrome (ARDS), an international normalized ratio 3 and spontaneous epistaxis. Unless volume is rapidly removed, as fresh frozen plasma is rapidly given, the patient is very likely to develop pulmonary oedema.血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）Age (years) 66 (5174) Reasons to start CRRTGender (male) 662/10

12、06 (65.8%) Oliguria/anuria 703/1002 (70.2%)Premorbid renal function High urea/creatinine 531/1002 (53.0%)Normal 590/1006 (58.6%) Metabolic acidosis 437/1002 (43.6%)Chronic impairment 283/1006 (28.1%) Fluid overload 368/1002 (36.7%)Unknown 133/1006 (13.2%) Hyperkalemia 186/1002 (18.6%)SAPS II 48 (396

13、2) Immunomodulation 136/1002 (13.6%)Predicted mortality (%) 41.5 (23.071.4) Others 70/1002 ( 7.0%)Hospital to ICU (days) 1 (07) ICU mortality 555/1003 (55.3%)ICU to start (days) 1.2 (0.44.1) Hospital mortality 641/ 999 (64.2%)Contributing factors to ARF SMR 1.38 (1.281.50)Sepsis/septic shock 504/100

14、3 (50.2%)Major surgery 377/1003 (37.6%)Low cardiac output 262/1003 (26.1%)Hypovolemia 201/1003 (20.0%)Drug induced 176/1003 (17.5%)Hepatorenal syndrome 73/1003 (7.3%)Obstructive uropathy 20/1003 (2.0%)Others 114/1003 (11.4%)Data are presented as median and interquartile ranges (25th75th percentiles)

15、 or percentages; SAPS II,Simplified Acute Physiology score; Hospital to ICU, duration betweenhospital admission and intensive care unit admission; ICU to start, duration between intensive care unit admission and study inclusion; ARF, acute renal failure; SMR, standardized mortality ratio; ICU, inten

16、sive care unit病人基本情況Intensive Care Med (2007) 33:15631570CRRT mode AnticoagulationCVVH 531/1006 (52.8%) Unfractionated heparin 429/1000 (42.9%)CVVHDF 342/1006 (34.0%) Sodium citrate 99/1000 (9.9%)CVVHD 132/1006 (13.1%) Nafamostat mesilate 61/1000 (6.1%)CAVHD 1/1006 (0.1%) Low-molecular-weight 44/100

17、0 (4.4%)Dilution site for replacement fluid heparinPredilution 509/870 (58.5%) Prostacyclin 11/1000 (1.1%)Postdilution 361/870 (41.5%) Hirudin 9/1000 (0.9%)Filter material Heparin-protamine 6/1000 (0.6%)Polyacrylonitrile 457/975 (46.9%) Others b 3/1000 (0.3%)Polysulfone 209/975 (21.4%) Combination c

18、 7/1000 (0.7%)Polyamide 164/975 (16.8%) No anticoagulation 331/1000 (33.1%)Cellulose triacetate 89/975 (9.1%)Polymethyl-methacrylate 27/975 (2.8%)Polyarylether-sulfone 14/975 (1.4%)Cellulose diacetate 11/975 (1.1%)Others a 4/975 (0.4%)a 3 Polyester-polymer-alloy, 1 ethylene-vinyl alcohol; b 2 danapa

19、roid,1 warfarin; c 4 heparin-citrate, 2 heparin-prostacyclin, 1 nafamostat mesilate-low-molecular-weight heparinCRRT使用情況Intensive Care Med (2007) 33:15631570Hypotension 188/1000 (18.8%)Bleeding 33/997 (3.3%)Indwelling vascular catheter sites 13/997 (1.3%)Intra-abdominal 3/997 (0.3%)Gastrointestinal

20、3/997 (0.3%)Nostril 3/997 (0.3%)Sternal wound 3/997 (0.3%)Others a 8/997 (0.8%)Arrhythmia 43/1000 (4.3%)Atrial fibrillation 24/1000 (2.4%)Supraventricular tachycardia 7/1000 (0.7%)Cardiac arrest 4/1000 (0.4%)Bradycardia 3/1000 (0.3%)Ventricular tachycardia 3/1000 (0.3%)Atrial flutter 1/1000 (0.1%)Ve

21、ntricular fibrillation 1/1000 (0.1%)a Intracranial, lower leg, bone marrow aspiration site, oral, and pericardial并發(fā)癥Intensive Care Med (2007) 33:15631570Venkataraman et al, J Crit Care, 2002CRRT處方與實(shí)際完成的比較Intensive Care Med 1999;25:805-813. All Early starters: Late starters: p value (n = 100) BUN 60

22、mg/dl (n = 41) (n = 59)BUN prior to CRRT (mg/dl) 73.2 (39.6) 42.6 (12.9) 94.5 (28.3) 0.0001Serum creatinine prior to CRRT (mg/dl):nonrhabdomyolysis patients (n = 89)a 3.26 (1.8) 2.69 (1.6) 3.59 (4.3) 0.025Serum creatinine prior to CRRT (mg/dl)rhabdomyolysis patients only (n = 11) 5.94 (1.2) 5.73 (1.

23、06) 6.50 (1.8) 0.387Creatinine clearance prior to CRRT (ml/min)b 15.1 (19.3) 17.4 (26.4) 13.4 (11.6) 0.332Albumin prior to CRRT (g/dl)c 2.61 2.76 2.50 0.049Oliguric on CRRT day 1 (%) 46.00 56.10 39.00 0.091Heart rate (beats/min) 110.0 116.8 105.3 0.001Mean blood pressure (mmHg) 88.0 87.8 88.2 0.915C

24、ardiac index (l/min per m2) 5.07 4.95 5.15 0.525Stroke volume (ml) 91.8 85 96.6 0.056Oxygen delivery index(ml O2/min per m2) 738.8 707.6 760.4 0.239Patients meeting SIRS criteria prior to CRRT (%) 91.20 94.60 88.90 0.345Hospital day of CRRT initiation 15.8 (23.4) 10.5 (15.3) 19.4 (27.2) 0.0001a Beca

25、use of a different serum creatinine response, rhabdomyolysispatients are analyzed separately from nonrhabdomyolysis patientsb Two-hour early morning timed collections (incomplete data, n = 70)c Incomplete data (n = 91)Gettings et al., Intensive Care Med 1999Gettings et al., Intensive Care Med 1999 A

26、ll Early starters Late starters p valueHospital LOS (days) 50.3 (43.4) 46.5 (37.0) 53.0 (47.4) 0.459Duration of CRRT period (days)a 19.2 (16.5) 17.7 (15.1) 20.2 (17.5) 0.448Number of CRRT daysb 18.8 (16.3) 17.6 (15.2) 19.6 (17.1) 0.546Survival (%)c 28.0 39.0 20.30 0.041Recovery of renal function in

27、survivors (%) 96.40 100 91.60 0.248a Time course of CRRT period from start to finish (includes days without CRRT)b Actual number of days where CRRTwas employedc Of survivors (n = 28), 16 were early starters and 12 were late startersGettings et al., Intensive Care Med 1999J Card Surg 2004 ;19:17-20Eu

28、r J Cardiothorac Surg 血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）Am J Respir Crit Care Med Vol 162. pp 191196, 2000血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版） CRRT 常用治療模式比較常用治療模式比較 SCUF CVVH CVVHD CVVHDF血流量（血流量（ml/min） 50100 50200 50200 50200透析液流量（透析液流量（ml/min） 1020 1020清除率（清除率（L/24h） 1236 1436 2040超濾率（超濾率（ml/min） 25 825 24 812中分子

29、清除力中分子清除力 血濾器血濾器/透析器透析器 高通量高通量 高通量高通量 低通量低通量 高通量高通量置換液置換液 無無 需要需要 無無 需要需要溶質(zhì)轉(zhuǎn)運(yùn)方式溶質(zhì)轉(zhuǎn)運(yùn)方式 無無 對流對流 彌散彌散 對流彌散對流彌散有效性有效性 用于清除液體用于清除液體 清除較大分清除較大分 清除小分子清除小分子 清除中小分清除中小分 子物質(zhì)子物質(zhì) 物質(zhì)物質(zhì) 子物質(zhì)子物質(zhì) 41 % 57 % 58 %Saudan et al, Kidney Int 2006Saudan et al, Kidney Int 2006Bouman研究Bouman et al., Crit Care Med 2002Bouman e

30、t al., Crit Care Med 2002Bouman et al., Crit Care Med 2002Schiffl et al, NEJM 2002Schiffl研究：IHD劑量與預(yù)后關(guān)系Schiffl et al, NEJM 2002Schiffl研究：IHD劑量與預(yù)后關(guān)系Schiffl et al, NEJM 2002Schiffl研究：IHD劑量與預(yù)后關(guān)系Kellum, Nature Clin Pract Nephrol 2007治療劑量與預(yù)后的關(guān)系Palevsky et al, NEJM 2008; 349 (May 20)不同治療強(qiáng)度間死亡率比較RENAL研究：Ran

31、domized Evaluation of Normal versus Augmented Level Replacement Therapy Study KaplanMeier Estimates of the Probability of Death.Mortality at 28 days was similar in the higher-intensity and lower-intensity treatment groups (38.5% and 36.9%, respectively), and mortality at 90 days was the same (44.7%)

32、 in both groups.N Engl J Med 2009;361:1627-38.血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版） 碳酸氫鹽置換液成份及濃度鈉 135145 mmol/L鉀 04 mmol/L氯 85120 mmol/L碳酸氫鹽 3040 mmol/L鈣 1.251.75 mmol/L鎂 0.250.75 mmol/L (可加MgS

33、O4)糖 100200 mg/dl (5.511.1 mmol/L)血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）血液凈化標(biāo)準(zhǔn)操作規(guī)程（2010 版）Curr Opin Crit Care 12:538-43對急性腎衰不同地區(qū)治療模式的選擇Liao et al, Artif Organs 2003不同模式對血尿素氮的影響 CRRT (n = 65) IHD (n = 28) P valueTime to RRT (hr) 84 ( 80) 68 ( 60) 0.52Age (yr) 54.7 ( 15.4) 62.6 ( 13.4) 0.02GenderMale 45

34、 (69%) 17 (61%) 0.43Female 20 (31%) 11 (39%)Diagnostic groupMedical 46 (71%) 17 (61%)Surgical 12 (18%) 10 (36%) 0.23Transplant 7 (11%) 1 (3%)APACHE II score 25.1 ( 7.3) 23.5 ( 8.5) 0.37TISS 47.8 ( 1.3 ) 37.6 ( 2.0) 0.0001Mechanical ventilation 65 (100%) 28 (100%) 1.0Acute lung injury 32 (49%) 6 (21%

35、) 0.01Admission serum 289 ( 217) 410 ( 223) 0.02creatinine (moLL1)Vasoactive drugs required 40 (62%) 10 (36%) 0.02不同RRT模式病人的基本情況Jacka et al. CAN J ANESTH 2005 / 52: 3 / pp 327332 CRRT IHD P value (n = 65)* (n = 28)* Oliguria 600 moLL1 8 (12%) 5 (18%) 0.48Urea 35 mmoLL1 11 (17%) 10 (36%) 0.05K 6 mmoL

36、L1 3 (5%) 2 (7%) 0.62pH 5 gkg1min1 18 (27%) 6 (18%) 0.53Epinephrine 15 (23%) 1 (3%) 0.02Norepinephrine 29 (44%) 5 (15%) 0.014Cross over to alternate 18 (67%) 0 (0%) 0.002mode of RRTJacka et al. CAN J ANESTH 2005 / 52: 3 / pp 327332A) ICU survival vs RRT mode Survived DiedCRRT 29 (45%) 36 (55%)IHD 20

37、 (71%) 8 (29%) P = 0.02B) Hospital survival vs RRT mode Survived DiedCRRT 24 (37%) 41 (63%)IHD 14 (50%) 14 (50%) P = 0.24C) Renal recovery vs RRT mode Recovered Chronic dialysisCRRT 21 (87%) 3 (13%)IHD 5 (36%) 9 (63%) P = 0.0003Jacka et al. CAN J ANESTH 2005 / 52: 3 / pp 327332結(jié)果比較Clark et al, Blood

38、 Purif 2006腎功能的恢復(fù)Uchino et al, Int J Artif Organs 2007腎功能的恢復(fù)Bell et al, Intensive Care Med 2007腎功能的恢復(fù)Mehta et al (2002)腎功能的恢復(fù)Manns et al, Crit Care Med 2003腎功能的恢復(fù)Mehta RL, Letteri JM:Current Status ofRRT for ARF. AJN 1999;19:377-82誰管理CRRT？Ronco C et al: Management of severe ARFin critically ill pati

39、ents: Intl. Survey 345 ctrs.Nephrology Dial Transpl 2001;16:23037誰管理CRRT？Curr Opin Crit Care 12:538-43在ICU中誰管理RRTSome guidelines to deliver adequate CRRT on the ICU Start early: oliguria 24 hours or anuria 12 hours; uraemia25-30 mmol/l Prescribe adequate dialysis dose: daily Kt/V 1.2; UF volume35 ml

40、/kg/h Use (semi)synthetic biocompatible high-flux membranes Use the venovenous approach, preferably internal jugular vein Maximise UF flow rate, before adding slow-dialysisVan Bommel. Renal replacement therapy for acute renal failure on the intensive care unit: coming of age?Some guidelines to deliver adequate CRRT on the ICU In case of severe liver dysfunction, use bicarbonate as buffering anion Judicious use