急性腎損傷診療指南解讀版

急性腎損傷診療指南解讀版AboutAKIguidelineADQI:2002,RIFLEAKIN:2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011UKRenalAssociationFinalVersion08、03、11AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryAKI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(dá)80%指南推薦強(qiáng)度QualityofevidenceA－HighB－ModerateC－LowD－VerylowStrengthofremendationLevel1－strongLevel2－weakordiscretionary指南推薦強(qiáng)度Guideline1:AKI得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(shí)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(rèn)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(shí)以上。單用尿量改變作為判斷標(biāo)準(zhǔn)時(shí),需要除外尿路梗阻及其她導(dǎo)致尿量減少得原因采用KDIGO推薦得定義與分期標(biāo)準(zhǔn)AKI分期標(biāo)準(zhǔn)指南推薦血清肌酐與尿量仍然作為AKI最好得標(biāo)志物(1B)RIFLE分級2002年急性透析質(zhì)量倡議組(ADQI)制定了ARF得RIFLE分級診斷標(biāo)準(zhǔn)。BellomoR,etal、CritCare2004;8:R204-R212ConceptualmodelforAKIGuideline2:臨床評估2、1詳細(xì)得病史采集與體格檢查有助于AKI病因得判斷(1A)2、224小時(shí)之內(nèi)進(jìn)行基本得檢查,包括尿液分析與泌尿系超聲(懷疑有尿路梗阻者)(1A)Chapter2、2:Riskassessment大家學(xué)習(xí)辛苦了，還是要堅(jiān)持繼續(xù)保持安靜Chapter2、2:Riskassessment

AKIisdefinedasanyofthefollowing(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)

DefinitionandstagingofAKIOverviewofAKI,CKD,andAKD、OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD、AKIisasubsetofAKD、BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD、IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere、AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease、AKD

acutekidneydiseasesanddisorder符合以下任何一項(xiàng)AKI,符合AKI定義3個(gè)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(gè)月腎損傷<3個(gè)月AKI/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(gè)月>3個(gè)月AKDAKI3個(gè)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(gè)月<3個(gè)月NKD無異常Guideline3:PreventionandTreatmentofAKI3、1評估危險(xiǎn)因素(1B)年齡>75歲CKD(eGFR<60ml/min/1、73m2心力衰竭動(dòng)脈粥樣硬化性周圍血管病變肝臟疾病糖尿病腎毒性藥物得使用低血容量感染3、2評估容量狀態(tài)后適當(dāng)補(bǔ)液(1B)HIGHRISK3、3造影劑腎病評估危險(xiǎn)因素評估容量狀態(tài)造影前水化3、4繼發(fā)于橫紋肌溶解得AKI給予0、9%氯化鈉與碳酸氫鈉擴(kuò)容(1B)對具CI-AKI高風(fēng)險(xiǎn)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(kuò)容以預(yù)防CI-AKI

Guideline4:AKI得治療一般治療(1A)Stage-basedmanagementofAKIChapter2、3:EvaluationandgeneralmanagementofpatientswithandatriskforAKI補(bǔ)液治療Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI、(2B)Weremendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI、(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)補(bǔ)液治療:低血容量者:重復(fù)小劑量補(bǔ)液(250ml晶體液/膠體液)

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

藥物治療(1B)多臟器功能衰竭藥代動(dòng)力學(xué)改變(分布容積、清除、與蛋白結(jié)合)需要調(diào)整藥物劑量目前無特殊得藥物用于治療繼發(fā)于低灌注損傷/膿毒血癥得AKI(1B)袢利尿劑againstMehtaRL,PascualMT,SorokoSetal、Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure、JAMA2002;288:2547-2553HoKM,SheridanDJ、Meta-analysisoffrusemidetopreventortreatacuterenalfailure、BMJ2006;333(7565):420-425Chapter3、4:TheuseofdiureticsinAKIWeremendnotusingdiureticstopreventAKI、(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload、(2C)Effectoffurosemidevs、controlonall-causemortality、ReprintedfromHoKM,PowerBM、Benefitsandrisksoffurosemideinacutekidneyinjury、Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs、controlonneedforRRT、ReprintedfromHoKM,PowerBM、Benefitsandrisksoffurosemideinacutekidneyinjury、Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;TheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI、abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident、甘露醇mannitolisnotscientificallyjustifiedinthepreventionofAKI、Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWeremendnotusinglow-dosedopaminetopreventortreatAKI、(1A)Wesuggestnotusingfenoldopam(非諾多巴)topreventortreatAKI、(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKIEffectoflow-dosedopamineonmortality、ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal、Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath、AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212;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(dòng)劑,在降低全身血管阻力得同時(shí)增加腎血流量RESEARCHREMENDATION:WeremendfurthertrialsofANPatdosesbelow0、1mg/kg/min,forthepreventionortreatmentofAKI、ThereisapossibilitythatANPmightbeeffectiveifitisgivenatalowerdose(0、01–0、05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie;GlycemiccontrolandnutritionalsupportIncriticallyillpatients,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)GrowthfactorinterventionWeremendnotusingrebinanthuman(rh)IGF-1topreventortreatAKI、(1B)humanIGF-1:重組人胰島素樣生長因子1Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestnotusingaminoglycosidesforthetreat-mentofinfectionsunlessnosuitable,lessnephro-toxic,therapeuticalternativesareavailable、(2A)Wesuggestthat,inpatientswithnormalkidneyfunctioninsteadystate,aminoglycosidesareadministeredasasingledosedailyratherthanmultiple-dosedailytreatmentregimens、(2B)Weremendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours、(1A)Wesuggestmonitoringaminoglycosidedruglevelswhentreatmentwithsingle-dailydosingisusedformorethan48hours、(2C)Wesuggestusingtopicalorlocalapplicationsofaminoglycosides(e、g、,respiratoryaerosols,instilledantibioticbeads),ratherthani、v、application,whenfeasibleandsuitable、(2B)Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB、(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,weremendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed、(1A)OthermethodsofpreventionofAKI

inthecriticallyillWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT、(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension、(2D)Weremendnotusingoralori、v、NACforpreventionofpostsurgicalAKI、(1A)CI-AKI:預(yù)防對比劑急性腎損害Guideline5: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(huì)診提供專科意見合理得轉(zhuǎn)診方案密切監(jiān)護(hù)治療腎臟科與ICU醫(yī)生協(xié)作Whentorequestarenalreferral？Guideline6:RRT模式得選擇建議個(gè)體化治療！(1B)Kanagasundaram,2007Guideline7:

透析器與透析液得選擇透析器: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)透析液微生物得控制Guideline8:血管通路臨時(shí)建立靜脈-靜脈通路(1A)選擇足夠長度得透析導(dǎo)管以降低再循環(huán)率(1B)置管部位與導(dǎo)管類型需根據(jù)患者得病情選擇(2C)由經(jīng)驗(yàn)豐富得醫(yī)生負(fù)責(zé)置管(1A)實(shí)時(shí)超聲導(dǎo)引有助于置管(1D)對有進(jìn)展至CKD4-5期風(fēng)險(xiǎn)得患者,盡量避免行鎖骨下靜脈置管,保護(hù)患者得血管資源(1D)Guideline8:血管通路保護(hù)非優(yōu)勢側(cè)得上肢血管(2C)定期更換臨時(shí)導(dǎo)管以降低感染得風(fēng)險(xiǎn)(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(shí)使用(1D)以預(yù)防感染Guideline9:體外抗凝根據(jù)患者病情與RRT模式制定抗凝治療方案(1C)推薦枸櫞酸局部