crrt影響aki殘余腎功能嗎？課件

CRRT影響AKI剩余腎功能嗎？OutlineAKI的流行病學(xué)剩余腎功能的概念及臨床意義CRRT對剩余腎功能的影響及可能機制小結(jié)ARF的現(xiàn)狀-發(fā)生率逐年增加Community-basedincidencerates(per100000person-years)ofnondialysisrequiringARFbycalendaryearKidneyInt,2007;72(2):208–212Community-basedincidencerates(per100000person-years)ofdialysis-requiringARFbycalendaryearARF病死率居高不下JAmSocNephrol,2006;17:1143–1150ARF、ARF-D的發(fā)病率仍呈上升趨勢ARF病死率隨時間盡管呈下降趨勢，但是仍然高達25-40%ProspectiveobservationalstudySeptember2000toDecember2001at54hospitalsin23countriesOf29269criticallyillpatientsadmittedduringthestudyperiod,1738(5.7%;95%CI5.5%-6.0%)hadARFduringtheirICUstay,including1260whoweretreatedwithRRTJAMA.2005;294:813-818ThecriteriaforARF：少尿(12小時<200ml)或/和血尿素氮高于84mg/dL(30mmol/L)MortalitywithacutekidneyfailureJAMA.2005;294:813-818Overallhospitalmortalitywas60.3%RIFLEcriteria:incidenceandassociatedmortalityCriticalCare2006,10:R735383criticallyillpatientsin7ICUs,AKIoccurredin67%ofpatientsMortality:hazardratioof2.7Hasmortalityfromacuterenalfailuredecreased?TheAmericanJournalofMedicine(2005)118,827–832Reportedmortalityratesofpatientswithacuterenalfailurefrom1956to2003--Asystematicreviewoftheliterature-47years80wereincludedinourreviewwithatotalof15897patientsEpidemiologyofAKIBloodPurif2021;31:159–171MulticenterItalianStudyRIFLE-BasedDataOutlineAKI的流行病學(xué)剩余腎功能的概念及臨床意義CRRT對剩余腎功能的影響及可能機制小結(jié)剩余腎功能(ResidualrenalfunctionRRF)定義：是指腎臟受到損傷后健存腎單位的殘留功能，包括去除毒素、調(diào)節(jié)水電解質(zhì)和酸堿平衡以及多種內(nèi)分泌功能剩余腎功能與生存率NephrolDialTransplant2005;20:396–403NephrolDialTransplant.2021;26(9):2978-83.剩余腎功能與AKI長期預(yù)后正相關(guān)IntensityofRenalSupport不改善AKI病死率NEnglJMed2021;359:7-20.NEnglJMed2021;361:1627-38.Onceanorganisinjured

TryandassistafailingorganbytreatingtheunderlyingcauseTrytoforcethatorgantoworkhardermaynotbethebestapproachResttheinjuredorganshouldbesensibleAvoidsignificantadverseeventsCriticalCare2021,16:317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〔腹膜透析or血透、透析膜等〕其他JAmSocNephrol.2000Mar;11:556-64.OutlineAKI的流行病學(xué)剩余腎功能的概念及臨床意義CRRT對剩余腎功能的影響及可能機制小結(jié)CRRT特點穩(wěn)定的血流動力學(xué)持續(xù)穩(wěn)定的控制氮質(zhì)血癥和水電/酸堿平衡能夠不斷去除循環(huán)中的毒素或中分子物質(zhì)按需提供營養(yǎng)補充和藥物治療CRRTvsIRRTIHDPDCRRTHemodynamicstability…+++Osmopressurestability…++++Fluidremoval++++++Correctionofacidosis++++++UnlimitedPN/EN……++ClearancesSmallsolutes(<500d)++++++Largesolutes(>500d)…++++Mediatorremoval……++?Accessmorbidity++++Anticoagulationneeds+…+Simplicity++++++Recoveryofrenalfunction--IntheoryRemovefluidandsoluteslowlyMorestableHaemodynamicsMayhelptorevoveryofrenalfunctionCRRTRapidfluidremovalMayleadtohypotensionWithpotentialforfurtherrenalinjuryandprolongationofARFIRRTNephrologyDialysisTransplantation1997;12(5):870–2ComparedtoIRRT,CRRTcanhelptoraiseMAPTheCochraneLibrary2021,Issue3CRRTdecreasestherequiringofpressorTheCochraneLibrary2021,Issue3CRRTisassociatedwithmorestablehaemodynamicsthanIRRTRetrospectivecohortstudyPatswithARFandrequireddialysisbetweenApril1,1996,andMarch31,19992ICUinCanada.N=261CRRTIHDPAPACHEII2725.10.10BaselineSCr1361800.002MAPBeforeRRT74.787.2<0.001HospMortality71.9%42.2%<0.01Renalrecoveryinhosp80.0%62.5%0.06DurationofRRT14.7d14.5d0.91Costperweek(Can$)3486-51171341Survivor(Costpery)No-RRTRRT$11,192$73,273CRRT對ARF腎功能恢復(fù)的影響

－CRRT促進腎功能恢復(fù)CritCareMed2003;31:449–455CRRT：腎功能恢復(fù)32ICU，n=22021102Survived90daysCVVH：944〔85.7%〕IHD：158〔14.3%〕IntensiveCareMed(2007)33:773–780慢性透析8.3%慢性透析16.5%944CRRT1102存活90天7890天內(nèi)

慢性透析2690天內(nèi)

慢性透析158IHD結(jié)論：CRRT更有利于腎功能的恢復(fù)，但病死率無差異。CRRT：腎功能恢復(fù)1218patientsforARFin54ICUin23countriesIntJArtifOrgans2007;30(4):281-292腎功能恢復(fù)CRRT能促進腎功能恢復(fù)DesignRetrospectivecohortstudy32SwedishICUs2,202patientswithARF(excludeESRD)IntensiveCareMed.2007,33:773–780VA/NIHAcuteRenalFailure

TrialNetwork(ATN)Study1124patients27sites3yearsIntensiveManagementStrategy

(561patients)RandomizationStablehemodynamics(SOFA0-2)IHD6x/week@Kt/Vof~1.2/sessionIHD3x/week@Kt/Vof~1.2/sessionUnstablehemodynamics(SOFA3-4)CVVHDF@

35mL/kg/hr,orSLED/EDD6x/weekCVVHDF@

20mL/kg/hr,orSLED/EDD3x/weekLessIntensiveManagementStrategy

(563patients)NEnglJMed2021;359:7-20Nodifferenceon60daysmortalityKaplan–MeierPlotofCumulativeProbabilitiesofDeathVeryhighrateofintradialytichypotensionintheIHDgroup–comparedtoCRRT/SLEDtreatments:TwiceasmanyIHDtreatmentsrequiredincreasedvasopressorsupportSixtimesasmanyIHDtreatmentshadtobestoppedRenalrecoveryratewaslowerthanexpected(~50%at28days)–possiblyrelatedtohypotensionduringIHDATNTrial:ImportantResultsDebateofrecoveryofrenalfunction

--ResultsofMetaanalysisMetaanalysisshowsnodifferenceinmortalityandchronicdialysisdependenceofpatientswithARFamongCRRT,IRRTorSLEDJAMA.2021;299(7):793-805SafetyCRRTRequirecontinuousanticoagulationTimeislongerIRRTRapidfluidandsoluteremovelBleedingDepletionofnutrientsInfectionHypotensionArrhythmiaHypothermiaismorefrequentd