crrt影響aki殘余腎功能嗎學(xué)習(xí)教案

1、會計(jì)學(xué)1crrt影響影響aki殘余腎功能嗎殘余腎功能嗎第1頁/共36頁Kidney Int, 2007; 72(2): 208212pCommunity-based incidence rates (per 100 000 person-years) of dialysis-requiring ARF by calendar year第2頁/共36頁J Am Soc Nephrol, 2006; 17: 11431150pARF、ARF-D的發(fā)病率仍呈上升趨勢pARF病死率隨時(shí)間盡管呈下降趨勢，但是仍然高達(dá)25-40%第3頁/共36頁P(yáng)rospective observational stud

2、y September 2000 to December 2001 at 54 hospitals in 23 countriesOf 29 269 critically ill patients admitted during the study period, 1738 (5.7%;95% CI 5.5%-6.0%) had ARF during their ICU stay, including 1260 who were treated with RRTJAMA. 2005;294:813-818The criteria for ARF：少尿(12小時(shí)200ml)或/和血尿素氮高于84

3、 mg/dL (30 mmol/L)第4頁/共36頁Mortality with acute kidney failureJAMA. 2005;294:813-818Overall hospital mortality was 60.3%第5頁/共36頁Critical Care 2006, 10:R735383 critically ill patients in 7 ICUs, AKI occurred in 67% of patientsMortality :第6頁/共36頁The American Journal of Medicine (2005) 118, 827832Report

4、ed mortality rates of patients with acute renal failure from 1956 to 2003-A systematic review of the literature - 47years80 were included in our review with a total of 15 897 patients第7頁/共36頁Epidemiology of AKIBlood Purif 2011;31:159171Multicenter Italian StudyRIFLE-Based Data第8頁/共36頁第9頁/共36頁殘余腎功能(R

5、esidual renal function RRF)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)分泌功能第10頁/共36頁殘余腎功能與生存率 Nephrol Dial Transplant 2005;20: 396403Nephrol Dial Transplant. 2011;26(9):2978-83.第11頁/共36頁殘余腎功能與AKI長期預(yù)后正相關(guān)第12頁/共36頁N Engl J Med 2008;359:7-20. N Engl J Med 2009;361:1627-38.第13頁/共36頁Once an organ is inj

6、ured Try and assist a failing organ by treating the underlying causeTry to force that organ to work harder may not be the best approachRest the injured organ should be sensibleAvoid significant adverse events Critical Care 2012, 16:317 第14頁/共36頁在維持性透析患者中影響RRF的因素血壓年齡 性別 種族 藥物鈣磷代謝脂質(zhì)代謝內(nèi)分泌激素水平腎臟替代治療相關(guān)因素

7、（腹膜透析or血透、透析膜等）其他J Am Soc Nephrol. 2000 Mar;11:556-64.第15頁/共36頁第16頁/共36頁第17頁/共36頁IHDPDCRRTHemodynamic stability+Osmo pressure stability +Fluid removal+Correction of acidosis+Unlimited PN/EN+Clearances Small solutes (500d)+Mediator removal+?Access morbidity+Anticoagulation needs+Simplicity+第18頁/共36頁R

8、emove fluid and solute slowlyMore stableHaemodynamicsMay help to revoveryof renal function CRRTRapid fluid removal May lead to hypotensionWith potential for further renal injury andprolongation of ARFIRRTNephrology Dialysis Transplantation 1997;12(5):8702第19頁/共36頁The Cochrane Library 2008, Issue 3第2

9、0頁/共36頁The Cochrane Library 2008, Issue 3第21頁/共36頁CRRTIHDPAPACHE II2725.10.10Baseline SCr1361800.002MAP Before RRT74.787.20.001Hosp Mortality71.9%42.2%0.01Renal recovery in hosp80.0%62.5%0.06Duration of RRT14.7d14.5d0.91Cost per week (Can $)3486-51171341Survivor (Cost per y) No-RRT RRT $11,192 $73,2

10、73CRRT對對ARF腎功能恢復(fù)的影響腎功能恢復(fù)的影響CRRT促進(jìn)腎功能恢復(fù)促進(jìn)腎功能恢復(fù)Crit Care Med 2003; 31:449 455第22頁/共36頁Intensive Care Med (2007) 33:773780慢性透析8.3%慢性透析16.5%944 CRRT1102 存活90天78 90天內(nèi) 慢性透析26 90天內(nèi) 慢性透析158 IHD結(jié)論：CRRT更有利于腎功能的恢復(fù)，但病死率無差異。第23頁/共36頁Int J Artif Organs 2007; 30 (4) : 281-292腎功能恢復(fù)vCRRT能促進(jìn)腎功能恢復(fù)第24頁/共36頁Intensive Ca

11、re Med. 2007, 33:773780第25頁/共36頁1124 patients 27 sites 3 yearsIntensive Management Strategy(561 patients)RandomizationStable hemodynamics(SOFA 0-2)IHD 6x/week Kt/V of 1.2/sessionIHD 3x/week Kt/V of 1.2/sessionUnstable hemodynamics(SOFA 3-4)CVVHDF 35 mL/kg/hr, orSLED/EDD 6x/weekCVVHDF 20 mL/kg/hr, orSLED/EDD 3x/weekLess Intensive Management Strategy(563 patients)N Engl J Med 2008;359:7-20第26頁/共36頁KaplanMeier Plot of Cumulative Probabilities of Death第27頁/共36頁第28頁/共36頁JAMA. 2008;299(7):793-805第29頁/共36頁uBleedinguDepletion of nutrientsuInfectionuHypotensionu