kdigo急性腎損傷指南解讀ppt課件

1、KDIGO急性腎損傷指南解讀,1,KDIGO Clinical Practice Guideline for Acute Kidney Injury,Kidney inter. Suppl. 2012; 2: 1–138,2,GRADE 系統(tǒng),3,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:9 14.8%,1B:10 16.4%,1C:3 4.9%,2A:2 3.3%,2B:10 16.4

2、%,2C:20 32.8%,2D:7 11.5%,4,內(nèi)容,Introduction and MethodologyAKI DefinitionPrevention and Treatment of AKIContrast-induced AKIDialysis Interventions for Treatment of AKI,5,符合下列任何一條即可診斷 1. Increase in SCr by ≥0.3 mg/dl

3、(≥ 26.5 lmol/l) within 48 hours2. Increase in SCr to ≥ 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days3. Urine volume <0.5 ml/kg/h for 6 hours.,AKI 診斷(Not Graded),6,Stage

4、 Serum creatinine Urine output1 1.5–1.9 times baseline OR <0.5 ml/kg/h fo

5、r ≥0.3 mg/dl (≥ 26.5 mmol/l) increase 6–12 hours2 2.0–2.9 times baseline <0.5 ml/kg/h for

6、 ≥12 hours3 3.0 times baseline OR Increase in serum creatinine to <0.3 ml/kg/h for

7、 ≥ 4.0 mg/dl (≥ 353.6 mmol/l) ≥ 24 hours OR OR Initia

8、tion of renal replacement therapy Anuria for ≥ 12 hours OR, In patients <18 years, decrease in eGFR to <35 ml/min per 1.73 m2,AKI 分級(Not Graded),7,The cause of

9、 AKI should be determined wheneverpossible. (Not Graded),Selected causes of AKI requiringimmediate diagnosis and specifictherapies Recommended

10、 diagnostic testsDecreased kidney perfusion Volume status and urinary

11、 diagnostic indicesAcute glomerulonephritis, vasculitis, Urine sediment examination,interstitial nephritis, thrombotic serologic testing and

12、Microangiopathy hematologic testing Urinary tract obstruction

13、 Kidney ultrasound,8,We recommend that patients be stratified for risk of AKI according to their susceptibilities and exposures. (1B) Manage patients accordin

14、g to their susceptibilities and exposures to reduce the risk of AKI . (Not Graded)Test patients at increased risk for AKI with measurements of SCr and urine output to detect AKI. (Not Graded) Individualize frequency an

15、d duration of monitoring based on patient risk and clinical course. (Not Graded),9,Exposures SusceptibilitiesSepsis Dehydr

16、ation or volume depletionCritical illness Advanced ageCirculatory shock Female genderBurns

17、 Black raceTrauma CKDCardiac surgery (especially Chronic diseases (heart, lung, liver)with CPB) Major

18、noncardiac surgery Diabetes mellitusNephrotoxic drugs CancerRadiocontrast agents AnemiaPoisonous plants and animals,Causes o

19、f AKI: exposures and susceptibilities for non-specific AKI,10,Evaluate patients with AKI promptly to determinethe cause, with special attention to reversiblecauses. (Not Graded) Monitor patients with AKI with measure

20、ments ofSCr and urine output to stage the severity, according to Recommendation . (Not Graded) Manage patients with AKI according to the stage and cause. (Not Graded),11,12,13,AKI時RRT治療時機,Initiate RRT emergently when

21、 life-threateningchanges in fluid, electrolyte, and acid-base balance exist. (Not Graded)Consider the broader clinical context, the presenceof conditions that can be modified with RRT, andtrends of laboratory tests—

22、rather than single BUNand creatinine thresholds alone—when making thedecision to start RRT. (Not Graded),14,Potential applications for RRT,Applications CommentsRenal

23、 replacement This is the traditional, prevailing approach based on utilization of RRT when there is little or no residual

24、 kidney function.Life-threatening indications No trials to validate these criteria.Hyperkalemia Dialysis for hyper

25、kalemia is effective in removing potassium; however, it requires frequent monitoring of potassium levels and

26、adjustment of concurrent medical management to prevent relapses.Acidemia Metabolic acidosis due to AKI is often aggra

27、vated by the underlying condition. Correction of metabolic acidosis with RRT in these conditions depends on t

28、he underlying disease process.Pulmonary edema RRT is often utilized to prevent the need for

29、 ventilatory support; however, it is equally important to manage pulmonary edema in ventilated patients.Uremic complications(pericarditis, bleeding, etc.) I

30、n contemporary practice it is rare to wait to initiate RRT in AKI patients until there are uremic complica

31、tions,15,Potential applications for RRT,Applications CommentsNonemergent indicationsSolute control BUN reflects factors not directl

32、y associated with kidney function, such as catabolic rate and volume status.SCr is influenced by

33、 age, race, muscle mass, and catabolic rate, and by changes in its volume of distribution due

34、to fluid administration or withdrawal.Fluid removal Fluid overload is an important determinant of the timing of RRT initi

35、ation.Correction of acid-baseAbnormalities No standard criteria for initiating dialysis exist.,16,Potential applications for RRT,Applications

36、 CommentsRenal support This approach is based on the utilization of RRT techniques as an adjunct to enhance kidney function, modify fluid balance, and control solute levels

37、.Volume control Fluid overload is emerging as an important factor associated with, and possibly contributing to, adverse outcomes in AKI. Recent studies have

38、 shown potential benefits from extracorporeal fluid removal in CHF. Intraoperative fluid removal using modified ultrafiltration has been shown to i

39、mprove outcomes in pediatric cardiac surgery patients.Nutrition Restricting volume administration in the setting of oliguric AKI may result in limited nutritional support and

40、 RRT allows better nutritional supplementation.Drug delivery RRT support can enhances the ability to administer drugs without concerns about concurrent fluid accumulation.Regulatio

41、n of Permissive hypercapnic acidosis in patients with lung injury can be corrected acid-base with RRT, without inducing fluid overload and hypernatremia.and electrolyte statusSolute

42、 Changes in solute burden should be anticipated (e.g., tumor lysis modulation syndrome). Although current evidence is unclear, studies are ongoing to assess the effica

43、cy of RRT for cytokine manipulation in sepsis.,17,AKI時停用RRT指征,Discontinue RRT when it is no longer required,either because intrinsic kidney function has recovered to the point that it is adequate to meet patient needs,

44、or because RRT is no longer consistent with the goals of care. (Not Graded),We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. (2B),18,抗凝治療,In a patient wit

45、h AKI requiring RRT, base the decision to use anticoagulation for RRT on assessment of the patient’s potential risks and benefits from anticoagulation . (Not Graded),We recommend using anticoagulation during RRT in AKI i

46、f a patient does not have an increased bleeding risk or impaired coagulation and is not already receiving systemic anticoagulation. (1B),19,For patients without an increased bleeding risk or impaired coagulation and not

47、already receiving effective systemic anticoagulation, we suggest the following:,For anticoagulation in intermittent RRT, we recommend using either unfractionated or low-molecular-weight heparin,rather than other anticoa

48、gulants. (1C),For anticoagulation in CRRT, we suggest using regional citrate anticoagulation rather than heparin in patients who do not have contraindications for citrate. (2B),For anticoagulation during CRRT in patients

49、 who have contraindications for citrate, we suggest using either unfractionatedor low-molecular-weight heparin, rather than other anticoagulants. (2C),抗凝治療,20,For patients with increased bleeding risk who are not receiv

50、ing anticoagulation, we suggest the following for anticoagulation during RRT:,We suggest using regional citrate anticoagulation,rather than no anticoagulation, during CRRT in a patient without contraindications for citr

51、ate. (2C),We suggest avoiding regional heparinization during CRRT in a patient with increased risk of bleeding. (2C),抗凝治療,21,In a patient with heparin-induced thrombocytopenia(HIT), all heparin must be stopped and we re

52、commend using direct thrombin inhibitors (such as argatroban) or Factor Xa inhibitors (such as danaparoid or fondaparinux) rather than other or no anticoagulation during RRT. (1A),In a patient with HIT who does not have

53、severe liver failure, we suggest using argatroban rather than other thrombin or Factor Xa inhibitors during RRT. (2C),抗凝治療,22,23,血管通路,We suggest initiating RRT in patients with AKI viaan uncuffed nontunneled dialysis ca

54、theter, ratherthan a tunneled catheter. (2D),When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these preferences (Not Graded):* First choice: right jugular vein;* Second ch

55、oice: femoral vein;* Third choice: left jugular vein;*Last choice: subclavian vein with preference for the dominant side.,24,We recommend using ultrasound guidance fordial

56、ysis catheter insertion. (1A),We recommend obtaining a chest radiographpromptly after placement and before first use of aninternal jugular or subclavian dialysis catheter. (1B),We suggest not using topical antibiotics

57、over theskin insertion site of a nontunneled dialysis catheterin ICU patients with AKI requiring RRT. (2C),We suggest not using antibiotic locks for preventionof catheter-related infections of nontunneleddialysis cat

58、heters in AKI requiring RRT. (2C),血管通路,25,濾器選擇,We suggest to use dialyzers with a biocompatiblemembrane for IHD and CRRT in patients withAKI. (2C),26,RRT模式選擇,Use continuous and intermittent RRT as complementarytherapi

59、es in AKI patients. (Not Graded),We suggest using CRRT, rather than standardintermittent RRT, for hemodynamically unstablepatients. (2B),We suggest using CRRT, rather than intermittentRRT, for AKI patients with acute

60、brain injury orother causes of increased intracranial pressure orgeneralized brain edema. (2B),27,Typical setting of different RRT modalities for AKI (for 70-kg patient),28,Theoretical advantages and disadvantages of C

61、RRT, IHD, SLED, and PD,29,緩沖液的選擇,We suggest using bicarbonate, rather than lactate,as a buffer in dialysate and replacement fluid forRRT in patients with AKI. (2C) We recommend using bicarbonate, rather thanlactate,

62、 as a buffer in dialysate and replacementfluid for RRT in patients with AKI and circulatoryshock. (1B) We suggest using bicarbonate, rather than lactate,as a buffer in dialysate and replacement fluid forRRT in pati

63、ents with AKI and liver failure and/orlactic acidemia. (2B),30,We recommend that dialysis fluids and replacement fluids in patients with AKI, at a minimum, comply with American Association of Medical Instrumentation (AA

64、MI) standards regarding contamination with bacteria and endotoxins. (1B),緩沖液的選擇,31,Microbiological quality standards of different regulatory agencies,32,RRT劑量,The dose of RRT to be delivered should be prescribed before s

65、tarting each session of RRT. (Not Graded) We recommend frequent assessment of the actual delivered dose in order to adjust the prescription. (1B) Provide RRT to achieve the goals of electrolyte, acid-base, solute, and

66、fluid balance that will meet the patient’s needs. (Not Graded),33,RRT劑量,We recommend delivering a Kt/V of 3.9 per week when using intermittent or extended RRT in AKI. (1A) We recommend delivering an effluent volume of