急性腎損傷診療指南解讀,KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012,趙良斌,KDIGO：Kidney Disease Improving Global Outcomes,2012-KDIGO指南解讀,急性腎損傷(AKI)與急性腎衰竭(ARF),國(guó)際腎臟病和急救醫(yī)學(xué)界將ARF 改為急性腎損傷（Acute Kidney Injury, AKI）。AKI 覆蓋的腎損傷,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006Biesen WV et al. CJASN. 2006,About AKI guideline,ADQI：2002, RIFLEAKIN：2005, modified definition and staging systemKDIGO: 2011, First clinical guideline for AKIWaiting for published in this summerAKI guideline for AKI :2011UK Renal Association Final Version 08.03.11AKI guidlineKDIGO 2012KDIGO Clinical Practice Guideline for Acute Kidney Injury,AKI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：486630 pmp/yAKI需要RRT發(fā)病率：22203pmp/y醫(yī)院獲得AKI死亡率：1080%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,指南推薦強(qiáng)度,Guideline 1：AKI的定義與分期,符合以下情況之一者即可被診斷為AKI：48小時(shí)內(nèi)Scr升高超過26.5mol/L(0.3mg/dl)；Scr升高超過基線1.5倍確認(rèn)或推測(cè)7天內(nèi)發(fā)生；尿量0.5ml/（kgh），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它導(dǎo)致尿量減少的原因,采用KDIGO推薦的定義和分期標(biāo)準(zhǔn),AKI分期標(biāo)準(zhǔn),指南推薦血清肌酐和尿量仍然作為AKI最好的標(biāo)志物(1B),RIFLE分級(jí),2002 年急性透析質(zhì)量倡議組(ADQI)制定了ARF的 RIFLE 分級(jí)診斷標(biāo)準(zhǔn)。,Bellomo R, et al. Crit Care 2004;8:R204-R212,Conceptual model for AKI,Guideline 2：臨床評(píng)估,2.1 詳細(xì)的病史采集和體格檢查有助于AKI病因的判斷(1A)2.2 24小時(shí)之內(nèi)進(jìn)行基本的檢查，包括尿液分析和泌尿系超聲(懷疑有尿路梗阻者)(1A),Chapter 2.2: Risk assessment,Chapter 2.2: Risk assessment,AKI is defined as any of the following (Not Graded ): AKI is defined as any of the following (Not Graded ): KIncrease in SCr by X 0.3 mg/dl ( X26.5 lmol/l)within 48 hours; or KIncrease in SCr to X1.5 times baseline, whichis known or presumed to have occurred withinthe prior 7 days; orKUrine volume o0.5 ml/kg/h for 6 hours.Test patients at increased risk for AKI with measurements of SCr and urine output to detect AKI. ( Not Graded )Individualize frequency and duration of monitoring based on patient risk and clinical course. ( Not Graded ) Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes.(Not Graded ) he cause of AKI should be determined whenever possible. (Not Graded),Definition and staging of AKI,Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.,AKDacute kidney diseases and disorder,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%GFR60ml/min/1.73m2, 3個(gè)月腎損傷75歲CKD (eGFR3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,Guideline 9：體外抗凝,根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)推薦枸櫞酸局部抗凝降低出血風(fēng)險(xiǎn)(2C)具有出血風(fēng)險(xiǎn)的患者可選擇前列環(huán)素抗凝，但會(huì)引起血流動(dòng)力學(xué)不穩(wěn)定(2C)具有高出血風(fēng)險(xiǎn)的患者可采取無(wú)抗凝劑、鹽水沖洗的方法，但引起超濾量增加，透析效率下降及增加了透析膜破裂的風(fēng)險(xiǎn)(2C),Guideline 10：RRT處方,通過對(duì)RRT劑量的評(píng)估確保透析充分性(1A)每次(IHD）或每日（CRRT)評(píng)估透析劑量及充分性(1A)推薦伴有多器官功能衰竭的AKI患者行CRRT，后稀釋法超濾率25ml/kg/hr。前稀釋法的持續(xù)性血液濾過相應(yīng)的上調(diào)超濾率(1A)伴有多器官功能衰竭的AKI患者行間歇性血液透析治療治療時(shí)，必須達(dá)到單次透析URR 65%或eKt/V 1.2，或者進(jìn)行每日透析(1B),CRRT劑量,We recommend delivering an effluent volume of 2025 ml/kg/h for CRRT in AKI (1A) . This will usually require a higher prescription of effluent volume. (Not Graded ),臨床適應(yīng)癥,生化指標(biāo)適應(yīng)癥,RRT開始指征 (1B),Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balanceexist. ( Not Graded),早期應(yīng)用RRT治療？,“早”：定義不統(tǒng)一BUN27mmol/L開始RRT，死亡風(fēng)險(xiǎn)翻倍,危重病人伴有AKI時(shí)CRRT與IHD的利弊,CRRT與IHD相比具備以下優(yōu)點(diǎn)：穩(wěn)定的血流動(dòng)力學(xué)，緩慢、連續(xù)性清除液體和溶質(zhì)，溶質(zhì)清除率高; 持續(xù)穩(wěn)定地控制氮質(zhì)血癥及電解質(zhì)和水鹽代謝;清除炎癥介質(zhì)，能夠不斷清除循環(huán)中存在的毒素和中小分子物質(zhì); 改善營(yíng)養(yǎng)支持，保障營(yíng)養(yǎng)補(bǔ)充及藥物治療,維持內(nèi)環(huán)境穩(wěn)定。缺點(diǎn)：花費(fèi)大，機(jī)器昂貴，需要專業(yè)的醫(yī)護(hù)團(tuán)隊(duì)，治療期間不能外 出治療、檢查等。,當(dāng)AKI作為多臟器功能衰竭的一部分，需要提前進(jìn)入腎臟替代治療(1C)AKI患者臨床癥狀改善并出現(xiàn)腎功能恢復(fù)的早期征象應(yīng)適當(dāng)推遲RRT(1D)過早行RRT帶來的問題靜脈血栓的形成導(dǎo)管相關(guān)性感染抗凝治療導(dǎo)致的出血其他并發(fā)癥,CRRT與利尿劑,We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. ( 2B),Typical settin