急性腎損傷診療指南解讀教材課件

急性腎損傷診療指南解讀（優(yōu)選）急性腎損傷診療指南解讀版AboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryAKI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：486~630pmp/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(qiáng)度指南推薦強(qiáng)度Guideline1：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(shí)內(nèi)Scr升高超過26.5μmol/L(0.3

mg/dl)；②

Scr

升高超過基線1.5倍—確認(rèn)或推測(cè)7天內(nèi)發(fā)生；③

尿量＜0.5

ml/（kg·h），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)InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.采用KDIGO推薦的定義和分期標(biāo)準(zhǔn)Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.監(jiān)測(cè)乳酸和堿剩余水平controlonall-causemortality.AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.discontinuationofRRTinAKIisnotevident.Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.NACforpreventionofpostsurgicalAKI.5倍—確認(rèn)或推測(cè)7天內(nèi)發(fā)生；具有高出血風(fēng)險(xiǎn)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(xiǎn)(2C)慎用高分子量羥乙基淀粉1mg/kg/min,forthepreventionortreatmentofAKI.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.1詳細(xì)的病史采集和體格檢查有助于AKI病因的判斷(1A)GFR<60ml/min/1.2評(píng)估容量狀態(tài)后適當(dāng)補(bǔ)液(1B)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)。BellomoR,etal.CritCare2004;8:R204-R212ConceptualmodelforAKIGuideline2：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)2.224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)Chapter2.2:RiskassessmentChapter2.2:RiskassessmentAKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.3mg/dl(X26.5lmol/l)within48hours;

·or

KIncreaseinSCrtoX1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;

·orKUrinevolumeo0.5ml/kg/hfor6hours.

TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)

Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)

EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)

DefinitionandstagingofAKIOverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.AKD

acutekidneydiseasesanddisorder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%GFR<60ml/min/1.73m2,<3個(gè)月腎損傷<3個(gè)月AKI/CKD/AKD腎功能改變腎臟結(jié)構(gòu)改變AKI7天內(nèi)血肌酐升高50%2天內(nèi)血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3個(gè)月>3個(gè)月AKDAKI3個(gè)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(gè)月<3個(gè)月NKD無異常Guideline3：PreventionandTreatmentofAKI3.1評(píng)估危險(xiǎn)因素(1B)年齡>75歲CKD(eGFR<60ml/min/1.73m2心力衰竭動(dòng)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(píng)估容量狀態(tài)后適當(dāng)補(bǔ)液(1B)HIGHRISK3.3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(duì)具CI-AKI高風(fēng)險(xiǎn)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

Guideline4：AKI的治療一般治療(1A)Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIGFR<60ml/min/1.Werecommendnotusinglow-dosedopaminetopreventortreatAKI.discontinuationofRRTinAKIisnotevident.controlonneedforRRT.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMeta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CritCare2004;8:R204-R2125g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.BMJ2006;333(7565):420-4255

ml/（kg·h），且持續(xù)6小時(shí)以上。Thiswillusuallyrequireahigherprescriptionofeffluentvolume.2評(píng)估容量狀態(tài)后適當(dāng)補(bǔ)液(1B)Effectoffurosemidevs.監(jiān)測(cè)乳酸和堿剩余水平MehtaRL,PascualMT,SorokoSetal.arenalreferral？FriedrichJO,AdhikariN,HerridgeMS.discontinuationofRRTinAKIisnotevident.根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(ANP)toprevent(2C)ortreat(2B)AKI補(bǔ)液治療Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)補(bǔ)液治療：低血容量者：重復(fù)小劑量補(bǔ)液(250ml晶體液/膠體液）

密切監(jiān)測(cè)CVP和尿量監(jiān)測(cè)乳酸和堿剩余水平嚴(yán)重膿毒血癥者：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(dòng)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againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;AnnInternMed2005;142:510-5242評(píng)估容量狀態(tài)后適當(dāng)補(bǔ)液(1B)醫(yī)院獲得AKI死亡率：10~80%導(dǎo)管僅限于RRT治療時(shí)使用(1D)以預(yù)防感染(NotGraded)7天內(nèi)血肌酐升高50%Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.急性腎損傷診療指南解讀危重病人伴有AKI時(shí)CRRT與IHD的利弊WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.abeneficialroleforloopdiureticsinfacilitating根據(jù)患者病情和RRT模式制定抗凝治療方案(1C)05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；MehtaRL,PascualMT,SorokoSetal.腎臟科與ICU醫(yī)生協(xié)作腎臟科與ICU醫(yī)生協(xié)作Werecommendnotusingoralori.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.ADQI：2002,RIFLETheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI.abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident.甘露醇mannitolisnotscientificallyjustifiedinthepreventionofAKI.Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWerecommendnotusinglow-dosedopaminetopreventortreatAKI.（1A）Wesuggestnotusingfenoldopam（非諾多巴）topreventortreatAKI.(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKIEffectoflow-dosedopamineonmortality.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；多巴胺---不建議FriedrichJO,AdhikariN,HerridgeMS.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510-524降低腎灌注(Lauschke,KidneyInt2006)導(dǎo)致心律失常(Schenarts,CurrentSurgery2006)加重心肌、腸道缺血缺氧(Schenarts,CurrentSurgery2006)非諾多巴---不建議選擇性多巴胺A1受體激動(dòng)劑，在降低全身血管阻力的同時(shí)增加腎血流量RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.1mg/kg/min,forthepreventionortreatmentofAKI.ThereisapossibilitythatANPmightbeeffectiveifitisgivenatalowerdose(0.01–0.05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；GlycemiccontrolandnutritionalsupportIncriticallyillpatients,wesuggestinsulintherapytargetingplasmaglucose110–149mg/dl(6.1–8.3mmol/l).(2C)Wesuggestachievingatotalenergyintakeof20–30kcal/kg/dinpatientswithanystageofAKI.(2C)WesuggesttoavoidrestrictionofproteinintakewiththeaimofpreventingordelayinginitiationofRRT.(2D)Wesuggestadministering0.8–1.0g/kg/dofproteininnoncatabolicAKIpatientswithoutneedfordialysis(2D),1.0–1.5g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.7g/kg/dinpatientsoncontinuousrenalreplacementtherapy(CRRT)andinhypercatabolicpatients.(2D)WesuggestprovidingnutritionpreferentiallyviatheenteralrouteinpatientswithAKI.(2C）2，或者進(jìn)行每日透析(1B)由經(jīng)驗(yàn)豐富的醫(yī)生負(fù)責(zé)置管(1A)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)。Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Guideline2：臨床評(píng)估采用KDIGO推薦的定義和分期標(biāo)準(zhǔn)AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；AboutAKIguidelineGFR<60ml/min/1.(NotGraded)discontinuationofRRTinAKIisnotevident.保護(hù)非優(yōu)勢(shì)側(cè)的上肢血管(2C)腎臟科與ICU醫(yī)生協(xié)作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-AKIWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.難以糾正的容量負(fù)荷過重0g/kg/dofproteininnoncatabolicAKIpatientswithoutneedfordialysis(2D),1.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.GrowthfactorinterventionWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.（1B）humanIGF-1：重組人胰島素樣生長(zhǎng)因子1Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestnotusingaminoglycosidesforthetreat-mentofinfectionsunlessnosuitable,lessnephro-toxic,therapeuticalternativesareavailable.(2A)Wesuggestthat,inpatientswithnormalkidneyfunctioninsteadystate,aminoglycosidesareadministeredasasingledosedailyratherthanmultiple-dosedailytreatmentregimens.(2B)Werecommendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours.(1A)Wesuggestmonitoringaminoglycosidedruglevelswhentreatmentwithsingle-dailydosingisusedformorethan48hours.(2C)Wesuggestusingtopicalorlocalapplicationsofaminoglycosides(e.g.,respiratoryaerosols,instilledantibioticbeads),ratherthani.v.application,whenfeasibleandsuitable.(2B)Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB.(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.(1A)OthermethodsofpreventionofAKI

inthecriticallyillWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT.(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.(2D)Werecommendnotusingoralori.v.NACforpreventionofpostsurgicalAKI.(1A)CI-AKI:預(yù)防對(duì)比劑急性腎損害Guideline5：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(huì)診提供?？埔庖姾侠淼霓D(zhuǎn)診方案密切監(jiān)護(hù)治療腎臟科與ICU醫(yī)生協(xié)作Whentorequestarenalreferral？Guideline6：RRT模式的選擇建議個(gè)體化治療！(1B)Kanagasundaram,2007Guideline7：

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Guideline8：血管通路臨時(shí)建立靜脈-靜脈通路(1A)選擇足夠長(zhǎng)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(yàn)豐富的醫(yī)生負(fù)責(zé)置管(1A)實(shí)時(shí)超聲導(dǎo)引有助于置管(1D)對(duì)有進(jìn)展至CKD4-5期風(fēng)險(xiǎn)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)Guideline8：血管通路保護(hù)非優(yōu)勢(shì)側(cè)的上肢血管(2C)定期更換臨時(shí)導(dǎo)管以降低感染的風(fēng)險(xiǎn)(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(shí)使用(1D)以預(yù)防感染Guideline9：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)難以糾正的電解質(zhì)紊亂:低鈉血癥、高鈉血癥或高鈣血癥Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.5

ml/（kg·h），且持續(xù)6小時(shí)以上。慎用高分子量羥乙基淀粉Werecommendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours.GlycemiccontrolandnutritionalsupportWesuggestnotusingaminoglycosidesforthetreat-mentofinfectionsunlessnosuitable,lessnephro-toxic,therapeuticalternativesareavailable.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;(NotGraded)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.Guideline2：臨床評(píng)估(NotGraded)ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Werecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.>3周：建議用皮下隧道導(dǎo)管ADQI：2002,RIFLEAKIguidelineforAKI:201105mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；AKIguidline—KDIGO2012Guideline10：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Werecommenddeliveringaneffluentvolumeof20–25ml/kg/hforCRRTinAKI(1A).Thiswillusuallyrequireahigherprescriptionofeffluentvolume.(NotGraded)頑固性高鉀血癥>6.5mmol/L血尿素氮>27mmol/L難以糾正的代謝性酸中毒PH<7.15難以糾正的電解質(zhì)紊亂:低鈉血癥、高鈉血癥或高鈣血癥腫瘤溶解綜合癥伴有的高尿酸血癥和高