kdigoaki診療指南解讀

1、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）。AK

2、I 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 AKI

3、Waiting for published in this summerAKI guideline for AKI :2011UK Renal Association Final Version 08.03.11AKI guidline—KDIGO 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)

4、院）人群發(fā)病率：486~630 pmp/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%,指南推薦強度,指南推薦強度,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：① 48小時內(nèi)Scr升高超過26.5μmol/L(0.3 mg/dl)；② Scr

5、60;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小時以上。單用尿量改變作為判斷標(biāo)準(zhǔn)時，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,2002 年急性透析質(zhì)量倡議組(ADQI)制定了ARF的 RIFLE 分級診斷標(biāo)準(zhǔn)。,Bellomo

6、R, et al. Crit Care 2004;8:R204-R212,Conceptual model for AKI,Guideline 2：臨床評估,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

7、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 X

8、1.5 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 out

9、put 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

10、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 a

11、mong 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 diseas

12、es and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.,AKDacute kidney diseases and disorder,符合以下任何一項AKI, 符合AKI定義3個月內(nèi)在原來基礎(chǔ)上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2, <3個月腎損傷<3個月,AKI/CKD/AKD,Gu

13、ideline 3：Prevention and Treatment of AKI,3.1評估危險因素(1B)年齡>75歲CKD (eGFR<60ml/min/1.73m2心力衰竭動脈粥樣硬化性周圍血管病變肝臟疾病糖尿病腎毒性藥物的使用低血容量感染3.2評估容量狀態(tài)后適當(dāng)補液(1B),HIGHRISK,3.3造影劑腎病,3.4繼發(fā)于橫紋肌溶解的AKI給予0.9%氯化鈉和碳酸氫鈉擴(kuò)容(1B),對具CI-

14、AKI高風(fēng)險者：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,Guideline 4：AKI的治療,一般治療(1A),Stage-based management of AKI,,Chapter 2.3:Evaluation and general management ofpatients with and at

15、 risk for AKI,補液治療,In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion ofintravascular volume in patients at risk for

16、AKI or with AKI. (2B)We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for AKI. ( 1C) We suggest using protocol-based management of hemodynamic and oxygen

17、ation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting (2C) or in patients with septic shock (2C),補液治療：低血容量者： 重復(fù)小劑量補液(250ml晶體液/膠體液） 密切監(jiān)測CVP和尿量 監(jiān)測乳酸和堿剩余水平嚴(yán)重膿

18、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,目前無特殊的藥物用于治療繼發(fā)于低灌注損傷/膿毒血癥的AKI (1B),袢利尿劑,against,Mehta RL, Pascual MT, Soroko S et al. Diuretics, mortality, and nonrecovery of renal function in acute

19、renal failure. JAMA 2002; 288: 2547-2553 Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333 (7565): 420-425,Chapter 3.4: The use of diuretics in AKI,We recommend not u

20、sing diuretics to prevent AKI. (1B)We suggest not using diuretics to treat AKI, exceptin the management of volume overload. ( 2C),,Effect of furosemide vs. control on all-cause mortality. Reprinted from Ho KM, Power BM.

21、 Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283–293 with permission from John Wiley and Sons193;,,Effect of furosemide vs. control on need for RRT. Reprinted from Ho KM, Power BM. Bene

22、fits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283–293 with permission from John Wiley and Sons193;,,The use of diuretics in AKI,At present, thecurrent evidence does not suggest that furosemid

23、e can reduce mortality in patients with AKI.a beneficial role for loop diuretics in facilitatingdiscontinuation of RRT in AKI is not evident.,甘露醇,mannitol is not scientifically justified in the prevention of AKI.,Vasod

24、ilator therapy: dopamine,fenoldopam, and natriuretic peptides,We recommend not using low-dose dopamine toprevent or treat AKI. （1A）We suggest not using fenoldopam（非諾多巴）to prevent or treat AKI. ( 2C)We suggest not usin

25、g atrial natriuretic peptide(ANP) to prevent (2C) or treat ( 2B) AKI,,Effect of low-dose dopamine on mortality. Reprinted from Friedrich JO, Adhikari N, Herridge MSet al . Meta-analysis: low-dosedopamine increases urine

26、 output but does not prevent renal dysfunction or death.Ann Intern Med 2005; 142: 510–524 with permissionfrom American College of Physicians212；,,多巴胺---不建議,Friedrich JO, Adhikari N, Herridge MS. Meta-analysis: low-dose d

27、opamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510-524,降低腎灌注(Lauschke , Kidney Int 2006)導(dǎo)致心律失常(Schenarts , Current Surgery 2006)加重心肌、腸道缺血缺氧(Schenarts , Current

28、 Surgery 2006),非諾多巴---不建議,選擇性多巴胺A1受體激動劑，在降低全身血管阻力的同時增加腎血流量,RESEARCH RECOMMENDATION：We recommend further trials of ANP at doses below 0.1m g/kg/min, for the prevention or treatment of AKI.There is a possibility that ANP m

29、ight be effective if it isgiven at a lower dose (0.01–0.05 mg/kg/min) in patients prophylactically or with early AKI, and during a longer period than in previous large studie；,Glycemic control and nutritional support,In

30、critically ill patients, we suggest insulin therapy targeting plasma glucose 110–149 mg/dl(6.1–8.3 mmol/l). ( 2C)We suggest achieving a total energy intake of 20–30 kcal/kg/d in patients with any stage of AKI. (2C)We s

31、uggest to avoid restriction of protein intake with the aim of preventing or delaying initiation of RRT. ( 2D)We suggest administering 0.8–1.0 g/kg/d of protein in non catabolic AKI patients without need fordialysis ( 2D

32、), 1.0–1.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients. ( 2D)We suggest providing nutrition prefer

33、entially via the enteral route in patients with AKI. (2C）,Growth factor intervention,We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI. （1B）,human IGF-1：重組人胰島素樣生長因子1,Prevention of aminoglycoside-

34、 andamphotericin-related AKI,We suggest not using aminoglycosides for the treat-ment of infections unless no suitable, less nephro-toxic, therapeutic alternatives are available. (2A)We suggest that, in patients with no

35、rmal kidney function in steady state, aminoglycosides are administered as a single dose daily rather thanmultiple-dose daily treatment regimens. (2B)We recommend monitoring aminoglycoside drug levels when treatment with

36、 multiple daily dosing is used for more than 24 hours. (1A)We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used for more than 48 hours. (2C)We suggest using topical or local

37、applications of aminoglycosides (e.g., respiratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. ( 2B),Prevention of aminoglycoside- andamphotericin-related AKI,We sugg

38、est using lipid formulations of ampho-tericin B rather than conventional formulations of amphotericin B. (2A)In the treatment of systemic mycoses or parasitic infections, we recommend using azole antifungal agents and/o

39、r the echinocandins rather than conventional amphotericin B, if equal therapeutic efficacy can be assumed.(1A),Other methods of prevention of AKIin the critically ill,We suggest that off-pump coronary artery bypass graf

40、t surgery not be selected solely for the purpose of reducing perioperative AKI or need for RRT. (2C)We suggest not using NAC to prevent AKI in critically ill patients with hypotension. (2D)We recommend not using oral o

41、r i.v. NAC for prevention of postsurgical AKI. (1A),CI-AKI:預(yù)防對比劑急性腎損害,Guideline 5：醫(yī)療資源合理分配,多學(xué)科參與AKI指南制定腎科醫(yī)生會診提供專科意見合理的轉(zhuǎn)診方案密切監(jiān)護(hù)治療腎臟科與ICU醫(yī)生協(xié)作,When to request a renal referral？,Guideline 6：RRT模式的選擇,,,,建議個體化治療！(1B),Ka

42、nagasundaram,2007,Guideline 7：透析器和透析液的選擇,,,,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)透析液微生物的控制,Guideline 8：血管通路,,,,,臨時建立靜脈-靜脈通路(1A)選擇足夠長度的透析導(dǎo)管以降低再循環(huán)率(1B)置管部位和導(dǎo)管類型需根據(jù)患者的病情選擇(2C)由經(jīng)驗豐富的醫(yī)生負(fù)責(zé)置管(1A)實時超聲導(dǎo)引有助于置

43、管(1D)對有進(jìn)展至CKD4-5期風(fēng)險的患者，盡量避免行鎖骨下靜脈置管，保護(hù)患者的血管資源(1D),Guideline 8：血管通路,保護(hù)非優(yōu)勢側(cè)的上肢血管(2C)定期更換臨時導(dǎo)管以降低感染的風(fēng)險(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

44、風(fēng)險(2C)具有出血風(fēng)險的患者可選擇前列環(huán)素抗凝，但會引起血流動力學(xué)不穩(wěn)定(2C)具有高出血風(fēng)險的患者可采取無抗凝劑、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(2C),Guideline 10：RRT處方,,,,通過對RRT劑量的評估確保透析充分性(1A)每次(IHD）或每日（CRRT)評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/

45、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，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 20–25 ml/kg/h for CRRT in AKI (1A) . This will usually requir

46、e 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”：

47、定義不統(tǒng)一BUN27mmol/L開始RRT，死亡風(fēng)險翻倍,危重病人伴有AKI時CRRT與IHD的利弊,CRRT與IHD相比具備以下優(yōu)點：①穩(wěn)定的血流動力學(xué)，緩慢、連續(xù)性清除液體和溶質(zhì)，②溶質(zhì)清除率高; ③持續(xù)穩(wěn)定地控制氮質(zhì)血癥及電解質(zhì)和水鹽代謝;④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); ⑤改善營養(yǎng)支持，保障營養(yǎng)補充及藥物治療,維持內(nèi)環(huán)境穩(wěn)定。缺點：花費大，機(jī)器昂貴，需要專業(yè)的醫(yī)護(hù)團(tuán)隊，治療期間不能外

48、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

49、 duration or frequency of RRT. ( 2B),Typical setting of different RRT modalities for AKI (for 70-kg patient),We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients. (2B),Guide