ICU中的血液凈化指南之我見(jiàn)

ICU中的血液凈化指南之我見(jiàn)ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56IntroductionMethodsofextracorporealrenalreplacementtherapy(RRT)havebeenusedforthesupportivetreatmentofAKIforover60years.CRRTforthecriticallyillpatientwithARFwasintroducedin1977byKrameretal.Sincethen,manystudieshavereportedonCRRTinthecriticallyill.KlinWochenschr1977;55:1121-1122.IntroductionButforseveralreasonscomparisonamongstudiesisdifficult:Varioustreatmentmodalitieshavebeenappliedinheterogeneouspopulations.DifferencesinclinicalsettingandunderlyingmolecularbiologicalmechanismsthatinitiateandmaintainARF.Furthermore,morethan35definitionsofARF.Practicepatternsvarywidelybetweenindividualcenters.Uptonow,therearenostandardguidelinesfortheapplicationofCRRTincriticallyillpatients.CurrOpinCritCare2002;8:509-514.IntroductionTheRIFLEClassificationforacuterenalfailureCritCare2004;8:R204-R212.IntroductionConclusions:Morethen200differentdefinitionsofARFandabout90RRTstartcriteriawerereported.OliguriaandRIFLEwerethemostfrequentcriteriausedtodefineARF.RIFLEcriteriamightshowaclinicalimpactonfuturedailypracticeandresearch.DifferentRRTtechniquesareavailableinmostcenters,butagenerallackoftreatmentdosestandardizationisnotedbyoursurvey.Non-renalindicationstoRRTstillneedtofindadefinitiveroleinroutinepractice.NephrolDialTransplant(2006)21:690–696Inthepast,theinteractionbetweennephrologyandintensivecarewasminimal.Today,thereiscontinuousinteractionwithseveralmomentsofhighinteractionduetocommonpatientsandcomplexsyndromes,andmuchofthetreatmentofAKIhasmovedfromtherenalwardintoICUs.IntroductionContribNephrol.Basel,Karger,2010(166):1–3ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseorintensityofCRRT4Conclusions56TypeoftherapyClassificationofbloodpurificationincriticalcare(BPCC)technologyPMX=polymyxin-Bimmobilizedfiber;PMMA=polymethylmethacrylate;PAN=polyacrylonitrile;PEPA=polyetherpolymeralloyContribNephrol.Basel,Karger,2010(166):11–20TypeoftherapyAsacontinuoustherapy,CRRTcanberapidlytailoredtochangesinapatient’sclinicalconditionduringcriticalillnessBloodpurificationincriticalcareContribNephrol.Basel,Karger,2010(166):11–20HDF=hemodiafiltrationTypeoftherapyTheseadvantageshavecontributedtothewidespreaduptakeofCRRTasthefirst-choiceRRTinICUsthroughoutAustralia,JapanandEurope.Intheseregions,CRRTisusuallyinitiatedandmanagedwithintheICU,withRRTbeingintegratedwithotheraspectsofthemanagementofcriticalillnessNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyInnorthAmerica,however,traditionalstructuresofICUmanagementfavoran‘open-ICU’approach:Withinthismodel,RRTisusuallyprescribedbyanephrologistintheICUandisinitiatedbyadialysisnurseInthisenvironment,IHDhastheadvantageofrequiringonlydailyoralternate-dayattendancebytherenalteamConversely,therelativelaborcostsofprovidingCRRTareincreased,aneffectthatiscompoundedbythelargerfixedcostsandhigherconsumablerequirementsofCRRTTheselogisticfactorshaveledtoapreferenceforIHDoverCRRTbeingmaintainedinICUsthatusethenorthAmerican.Nat.Rev.Nephrol.2010:6:521–529.TypeoftherapyClinicalstudiesofCRRTintheICUThediversityofclinicalapproachestothetreatmentofAKIintheICUisillustratedbytheresultsoftheBESTKidneystudy,ThemultinationalepidemiologicalstudyofRRTpracticeintheICUStudydocumentedthetreatmentofAKIin1,738patientsin54ICUsonfivecontinentsNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyBESTstudyresultsCRRTwasthemostcommonchoiceofinitialRRTtreatment,with80%ofpatientsonCRRT;IHDusewasmostlyrestrictedtoICUsinnorthandsouthAmerica,whereitwasusedasinitialtherapyin30–40%ofpatients,while,bycontrast,CRRTisusedfirstin100%ofICUsinAustralia.AmongpatientsreceivingCRRT,however,markedvariationinthemodality,intensity,timingwasobservedMakingitdifficulttocompareoutcomesbetweenpatientsonCRRTandthoseonIHDNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyNat.Rev.Nephrol.2010:6:521–529.有些研究表明在ICU不穩(wěn)定的患者中應(yīng)用IHD也不會(huì)存在明顯的問(wèn)題,

有RCTs并沒(méi)有顯示出CRRT優(yōu)于IHDTypeoftherapyKidneyInt2009,76:422-427.BMCNephrol2010,11:32.NephrolDialTransplant2009,24:512-518.Lancet2006,368:379-385.

對(duì)于依賴血管活性藥物的AKI患者，CRRT才是最適合的；依賴血管活性藥物的AKI患者將來(lái)接受長(zhǎng)期透析的幾率CRRT<間斷性治療；AKI的急性期推薦應(yīng)用CRRT，尤其是對(duì)于嚴(yán)重血流動(dòng)力學(xué)不穩(wěn)定、需大量清除液體以便于進(jìn)行更有效藥物治療的患者。CritCareMed2008,36:610-617.KidneyInt2009,76:422-427.NatRevNephrol2010,9:521-529.ClinPharmacolTher2009,86:562-565.目前共識(shí)：ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56TimingofCRRTTherighttimetostartRRTisstillatopicofdebate.主要的原因的是：沒(méi)有一個(gè)明確的、協(xié)商一致的AKI定義能夠根據(jù)腎損傷程度對(duì)患者進(jìn)行分級(jí)研究時(shí)很難獲得同種類相同特征的患者組人群RIFLE和AKIN分級(jí)標(biāo)準(zhǔn)使對(duì)于AKI的研究向前邁進(jìn)了一大步兩種分級(jí)標(biāo)準(zhǔn)均能使臨床醫(yī)生警惕AKI的出現(xiàn)，進(jìn)行早期干預(yù)CritCare2009,13:211.TimingofCRRTThereissignificantvariationinthetimingofinitiationofRRT,withuptotwo-folddifferencesinthereportedvaluesofBUN,creatinine,orurineoutputatRRTinitiation.ClinicalstudiesevaluatingthetimingofinitiationofCRRTincriticallyillpatientsTimingofCRRTIntheabove-mentionedstudiesthereisacleartrendtowardabetteroutcomewithearliertimingofRRT.IntheabsenceoflargeRCTscomparingearlytolateinitiationofRRT,nofirmoverallrecommendationsfortimingofRRTcanbemade.TimingofCRRT目前廣為接受的SepticAKI開(kāi)始RRT時(shí)機(jī)，尤其是在septicshock時(shí)：RIFLEinjurystage(orAKINstage2)butconsensusonthistopicawaitsresultsfromlarge-scaleRCTs.TimingofCRRT除AKI外，患者的一些其他情況也需要行早期RRT治療：mainlypediatric,treatedbyECMOforsevereARDS.Fluidoverloaddefinitelyplaysaroleintiming,becauseCRRTprovedsuccessfulinpatientswithoutAKIbutrefractorytodiuretics.治療時(shí)機(jī)的標(biāo)準(zhǔn)在不斷發(fā)展，包括：severityoforgandysfunction(SOFAscore)；severityofAKI(RIFLEorAKINstage)；fluidoverloadstatus；

timefromadmission；biomarkeruse,etc.但他們?cè)谌粘ＥR床實(shí)踐中的應(yīng)用價(jià)值仍然需要評(píng)估KidneyInt2010,77:469-470.KidneyInt2009,76:1289-1292JAmSocNephrol2011,22:810-820.TimingofCRRTWheninitiationofRRTisconsidered,itisimportanttorealizethat:theconsequencesofureamictoxicity,metabolicacidosisand/orfluidoverloadarelikelytobemoresevereinthecriticallyillpatient.Moreover,renalfunctionisunlikelytorecoverwithinashortperiodduringpersistentandseverefailureofotherorgans.Furthermore,variousinflammatorymediatorsareclearedbythekidney.TimingofCRRT最近的一項(xiàng)前瞻性研究和兩項(xiàng)meta-analysis明確地支持earlytimingThefindingsofthesestudiessupportearlierinitiationofacuteRRTIntheabsenceofnewevidencefromsuitably-designedrandomisedtrials,adefinitivetreatmentrecommendationcannotbemadeContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56DoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTBoththeATNandRENALstudiesfailedtodetectanysurvivalbenefitfrommore-intensiveRRTAndnosignificantdifferencesinmortalityrateswereobservedbetweenhigh-intensityandlow-intensitytreatmentinsubgroupsineitherstudy.TheseresultsprovidedefinitiveevidencetorecommendthatescalationofCRRTintensitytobeyondconventionaldosesof25ml/kg/hisnotbeneficialforunselectedICUpatientswithAKI.PossiblerelationshipbetweendelivereddoseofCRRTandsurvival,withresultsfromtheATNandRENALtrialsillustrated.DoseorintensityofCRRT而關(guān)于non-septicAKI的治療劑量，RENAL研究得到了一個(gè)明確的答案:RandomizedEvaluationofNormalversusAugmentedLevels(RENAL)study:nobeneficialeffectofCVVHDFat40ml/kg/hcomparedwith25ml/kg/h.Therefore,currentconsensussuggestsahemofiltrationdoseof25ml/kg/hinnon-septicAKIwithnoadditionalbenefitfromadoseincrease.NEnglJMed2009,361:1627-1638.DoseorintensityofCRRT然而，需要強(qiáng)調(diào)的是：專家的意見(jiàn)是患者治療劑量要足夠，至少25ml/kg/h。但實(shí)際中由于存在可預(yù)測(cè)的（bagschange,nursing...）和不可預(yù)測(cè)的（surgery,clotting...）治療中斷，意味著劑量要在30-35ml/kg/h；SepticAKI患者的治療劑量目前仍存在爭(zhēng)議，一些小的前瞻隨機(jī)研究表明高劑量的血液濾過(guò)是有益的。多中心的“IVOIREstudy”(hIghVolumeinIntensivecare)，在sepsis引起的AKI，休克和多臟衰患者中，比較35ml/kg/h

vs.70ml/kg/h

，不久后，可能會(huì)對(duì)治療劑量的爭(zhēng)論有所定論。Joannes-BoyauO,HonorePM:HemofiltrationStudy:IVOIREStudy:IDNCT00241228.,lastAccessedinJune2011.CritCare2009,13:R57.JNephrol2011,24:165-176.DoseorintensityofCRRT“IVOIREstudy”(hIghVolumeinIntensivecare)初步結(jié)果：Althoughpatientsincludedweremoreseverelyill,overallmortalityintheIVOIREstudyremainsverylow(39%at28daysand52%at90days)comparedwiththeRENALstudy.Thismaybeduetotheearlierstartoftreatmentattherenalinjurylevel.Awaitingresultsfromthisimportanttrial,35ml/kg/hshouldremainthestandarddoseinsepticAKI,particularlyinthepresenceofshock.Joannes-BoyauO,HonorePM:HemofiltrationStudy:IVOIREStudy:IDNCT00241228.,lastAccessedinJune2011.ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56RRTinICU:PreferenceDecisionaboutwhichtechniquetousedependson:1.WhatwewanttoremovefromtheplasmaRRTinICU:Preference2.Thepatient`scardiovascularstatusCRRTcauseslessrapidfluidshiftsandisthepreferredoptionifthereisanydegreeofcardiovascularinstability.3.TheavailabilityofresourcesCRRTismorelabourintensiveandmoreexpensivethanIHDAvailabilityofequipmentmaydictatetheformofRRTRRTinICU:Preference4.Theclinician`sexperienceItiswisetouseaformofRRTthatisfamiliartoallthestaffinvolved5.

OtherspecificclinicalconsiderationsConvectivemodesofRRTmaybebeneficialifthepatienthassepticshockCRRTcanaidfeedingregimesbyimprovingfluidmanagementCRRTmaybeassociatedwithbettercerebralperfusioninpatientswithanacutebraininjuryorfulminanthepaticfailure許多問(wèn)題懸而未決標(biāo)準(zhǔn)與個(gè)體化Youareunique!Standard!KeyPointsItisrecommendedtodefineARFaccordingtotheRIFLEclassificationsystemintoARFrisk,ARFinjuryandARFfailure.ItisrecommendedtobasethedecisionwhentostartRRTnotonlyontheseverityofARF,butalsoontheseverityofotherorganfailure.InitiationofRRTistobeconsideredinoliguricpatients(RIFLErisk-oliguriao