CRRT 連續(xù)腎臟替代療法課件

1、CRRT山東大學(xué)齊魯醫(yī)院 田軍持續(xù)腎臟替代治療（Continuous Renal Replacement Therapy, CRRT) Any extracorporeal blood purification therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours/day危重病人的腎臟替代治療持續(xù)腎臟替代治療（Continuous Renal Replacem

2、ent Therapy)間斷血液透析(Intermittent Hemodialysis)持續(xù)腎臟替代治療（Continuous Renal Replacement Therapy, CRRT)的特點(diǎn)低血壓患者：緩慢、溫和、耐受性好在較長(zhǎng)的時(shí)間內(nèi)，清除大量的水和廢物血流動(dòng)力學(xué)不穩(wěn)定患者耐受性好CRRT的目的危重癥采用CRRT的目的主要有兩大類:一是重癥患者并發(fā)腎功能損害；二是非腎臟疾病或腎功損害的重癥狀態(tài)，主要用于器官功能不全支持、穩(wěn)定內(nèi)環(huán)境、免疫調(diào)節(jié)等。 血液透析濾過(guò)對(duì)流（血液濾過(guò)）+彌散（血液透析）使用置換液+透析液CVVHReturn Pressure Air Detector Retu

3、rn Clamp Patient Access Pressure Effluent Pump Syringe Pump Filter PressureHemofilter Pre Post Post Replacement Pump Replacement Pump Pre Blood Pump Effluent Pressure CVVH治療時(shí)機(jī)，模式選擇，治療劑量AKI的定義和分類KDIGO推薦，符合以下情況之一者即可被診斷為AKI： 48小時(shí)內(nèi)血清肌酐（Scr）升高超過(guò)26.5 mol/L（0.3 mg/dl）； 7天內(nèi)Scr 升高超過(guò)基線1.5倍； 尿量0.5 ml/（kg?h），且持

4、續(xù)6小時(shí)以上。AKI分級(jí)標(biāo)準(zhǔn)見(jiàn)右表。AKD的定義在AKI指南中，KDIGO引入了AKD的新概念，即符合以下任何條件者即可被診斷為AKD： 符合AKI標(biāo)準(zhǔn)； 3個(gè)月內(nèi)腎小球?yàn)V過(guò)率（GFR）下降超過(guò)35%或Scr升高超過(guò)50%； 3個(gè)月內(nèi)GFR下降至60 ml/（min?1.73m2）以下； 腎臟損傷時(shí)間短于3個(gè)月。 緊急腎臟替代治療指征K6.5容量過(guò)多嚴(yán)重代謝性酸中毒尿毒癥性心包炎藥物過(guò)量ARF的輔助檢查Cr，BUN是最常用判斷腎功能的指標(biāo)敏感性差，通常腎小球?yàn)V過(guò)率下降50%以上才會(huì)增高受多種因素影響：營(yíng)養(yǎng)狀況、肌肉損傷、消化道出血、激素治療等增高水平較絕對(duì)值更敏感CRRT的類型CVVH Con

5、tinuous Veno-Venous Hemofiltration CVVHD Continuous Veno-Venous HemoDialysisCVVHDF Continuous Veno-Venous HemoDiaFiltrationSCUF Slow Continuous Ultra FiltrationARF預(yù)后病死率與既往腎功能狀況、本次發(fā)病情況、合并癥嚴(yán)重程度與數(shù)量有關(guān)呼吸衰竭、全身性感染、創(chuàng)傷、腹腔疾病、燒傷 7090%藥物性腎?。ò被沁?、造影劑等）2530%三個(gè)或三個(gè)以上臟器功能障礙病死率100%ARF的死亡原因感染是ARF最主要的死因耐藥的G-桿菌、真菌引起的全身性

6、感染其他導(dǎo)致死亡原因心血管功能障礙、呼吸衰竭（VAP），消化道出血RIFLE Stratification in Patients Treated with CRRTBell et al, Nephrol Dial Transplant 2005Conclusions:An increased treatment dose from 20 ml/h/kg to 35 ml/h/kg significantly improved survival.a dose of 35 ml/kg/hour was associated with dramatic improvement in surviva

7、l of nearly 20 %. A delivery of 45ml/kg/hr did not result in further benefit in terms of survival, but in the septic patient an improvement was observed. Our data suggest an early initiation of treatment and a minimum dose delivery of 35 ml/h/kg (ex. 70 kg patient = 2450 ml/h) improve patient surviv

8、al rate.Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 000.2.4.6.81020406080100IRRTCRRTdaysRecovery from Dialysis Dependence: BEST Kidney DataRecovery from dialysis dependenceManuscript under reviewLeading the wayCRRT vs. IHD in Renal RecoveryRecent studi

9、es suggest that CRRT is superior to IHD with respect to recovery of renal functionImplications go far beyond just “hard” endpoint of renal recovery Need for chronic dialysis impairs quality of lifeIf length of stay (LOS) in ICU can be reduced this will have a major impact on hospital budgetPatients

10、dependent on chronic dialysis will consume significant health care resources and have an impact on the community health care budgetLeading the wayTwo methods of high volume hemofiltration (HVHF), with different underlying concepts and results, became prevalent: Continuous high volume hemofiltration

11、(CHVH) providing 50 to 70 ml/kg/h 24 hours a day, intermittent high volume hemofiltration (IHVH) with brief, very high volume treatment at 100 to 120 ml/kg/h for 4 to 8 hours血液凈化治療非腎臟病的指征全身炎癥反應(yīng)綜合征/膿毒癥多器官功能障礙綜合征急性呼吸窘迫綜合征擠壓綜合征急性壞死性胰腺炎嚴(yán)重?zé)齻姆闻月冯娊赓|(zhì)紊亂乳酸酸中毒肝功能衰竭急、慢性心力衰竭藥物或毒物中毒先天性代謝缺陷急性腫瘤溶解綜合征連續(xù)性血液凈化在SIRS和M

12、ODS中的應(yīng)用連續(xù)性血液凈化在合并ARF的SIRS和MODS的患者治療中應(yīng)用越來(lái)越廣泛，除了用于控制患者的液體平衡、氮質(zhì)血癥和水電解質(zhì)酸堿平衡之外，還可能糾正膿毒癥導(dǎo)致的炎性介質(zhì)內(nèi)穩(wěn)態(tài)紊亂，如清除大量釋放的補(bǔ)體成分，花生四烯酸代謝產(chǎn)物和細(xì)胞因子等，改善血流動(dòng)力學(xué)和器官功能。具體如下：1、通過(guò)彌散或?qū)α鳟a(chǎn)生的吸附濾過(guò)作用清除促炎和抗炎介質(zhì)和血管活性物質(zhì)。 2、與膜接觸有關(guān)的反應(yīng)：(1)激活白細(xì)胞和前炎癥反應(yīng)； (2)消耗血小板。 3、其他作用：(1)降低血液溫度，治療發(fā)熱； (2)抗凝可能起到抗炎作用； (3)減輕組織水腫，改善供氧和器官功能； (4)清除乳酸； (5)補(bǔ)充置換液的作用； (6)

13、糾正代謝性酸中毒。The new concept of purification plasma challenge was then developed to try to decrease mortality. SIRS AND CRRTYearbook of Intensive Care And Emergency Medicine 2009 Some of the leading theories in this field are provided by current experts in hemofiltration.First, the peak concentration hy

14、pothesis of Ronco and Bellomo postulates that removing the peak cytokine concentration from the blood circulation during the early phase of sepsis could stop the inflammatory cascade and the accumulation of free cytokines, which are the leading cause of organ damage and homeostasis disruption The se

15、cond concept is called the threshold immunomodulation hypothesis, also called the Honore concept 9, 10. In this concept, the removal of cytokines does not only affect the cytokine concentration in the blood stream but also in the tissues. Indeed, when cytokine concentrations are reduced in the blood

16、, blood and tissue concentrations may equilibrate to remove the immune components trapped in the organs. This could explain why no crucial reduction in cytokine Concentration is observed in the blood stream during hemofiltration, because cytokines from the organs permanently replace those lost in th

17、e blood. The third theory, which has been proposed by Di Carlo, sheds new light on the mediator delivery hypothesis, in which the use of HVHF with a high volume of crystalloid fluids (3 to 5 l/hour) is able to increase the lymphatic flow by 20 to 40 fold .Indeed, this increase is correlated with the

18、 infusion of a high dose of fluids. Since cytokines and other immune components are transported by the lymphatic stream, this could explain their removal even though large amounts of cytokines were not found in ultrafiltration fluid. Thus, the use of high volumes of exchange fluid might be the princ

19、ipal motor of cytokine removal. although the benefit of early treatment has been shown, initiating RRT before renal injury is not yet recommended. In fact, the best time to start hemofiltration may be the renal injury state (creatinine 2 from baseline or oliguria III 0.5 ml/kg over the preceding 12

20、hours) from the RIFLE (Risk, Injury, Failure, Loss, and End-stage Kidney) classification which could represent the best compromise between early initiation and renal impairment 35 ml/kg/h should be the standard hemofiltration dose in ICUs for all patients with AKI, while in some situations, like sep

21、sis, the dose should be increased as a salvage therapy in view of the high mortality rates in these patients. However, more trials are needed before HVHF can be recommended as routine treatmentCRRT過(guò)程中監(jiān)測(cè)體液量的目的在于恢復(fù)患者體液的正常分布比率。嚴(yán)重的體液潴留或正水平衡可導(dǎo)致死亡率升高，而過(guò)度超濾體液也可以引發(fā)有效血容量缺乏。Vincent等在24個(gè)歐洲國(guó)家的198個(gè)ICU進(jìn)行的回顧性觀察顯示：

22、ICU病死率除與sepsis的發(fā)生率相關(guān)外，還同年齡和正水平衡密切相關(guān)。美國(guó)一項(xiàng)兒科ICU單中心回顧性研究中觀察到， CRRT治療前液體過(guò)負(fù)荷越重，死亡率越高，這意味著液體過(guò)負(fù)荷對(duì)預(yù)后有重要影響。基于以上基礎(chǔ)，該中心應(yīng)用利尿劑、小劑量多巴胺及RRT策略控制并發(fā)ARF的干細(xì)胞移植兒童的液體量，觀察發(fā)現(xiàn)有效糾正液體過(guò)負(fù)荷可降低病死率。因此， RRT過(guò)程中，在維持生命體征穩(wěn)定的前提下，應(yīng)控制液體入量，避免體液潴留。 正水平衡病人死亡率高急性壞死性胰腺炎急性壞死性胰腺炎（SAP）的發(fā)病機(jī)制是胰蛋白酶的大量活化，消化胰腺組織，同時(shí)胰蛋白酶進(jìn)人血液循環(huán)，作用于各種不同的細(xì)胞，釋放出大量血管活性物質(zhì)（5-羥

23、色胺、組織胺、激肽酶），導(dǎo)致胰腺壞死，炎癥反應(yīng)，血管彌漫性損傷，血管張力改變，引起心血管、肝和腎臟功能不全。急性胰腺炎的治療進(jìn)展包括應(yīng)用單克隆和多克隆抗體，中和及清除各種炎癥介質(zhì)和毒素。Purcaru等提出在胰腺炎毒性物質(zhì)未進(jìn)人血液之前采用CBP，同時(shí)進(jìn)行胸腔和腹腔灌洗。已有動(dòng)物實(shí)驗(yàn)資料顯示,SAP開(kāi)始CBP時(shí)間的早晚對(duì)動(dòng)物的預(yù)后有顯著影響。擠壓綜合征擠壓綜合征是指肌肉豐富的肢體或軀干，受外界重物（如被倒塌的工事，房屋）擠壓或固定體位自壓1小時(shí)以上而造成的肌肉組織創(chuàng)傷，肌肉發(fā)生缺血壞死，在此基礎(chǔ)上出現(xiàn)腎臟的缺血缺氧，腎血管痙攣，肌紅蛋白可變成為不可溶性的血紅蛋白，沉淀于腎小管內(nèi)，從而加速ARF

24、的發(fā)展。如處理不當(dāng)，在解除擠壓后，除了局部病變外，還可并發(fā)休克，形成危及生命的擠壓綜合征。二次大戰(zhàn)時(shí)，死亡率高達(dá)90100；1976年，唐山地震后，死亡率在2040。 近年來(lái)，由于血液凈化技術(shù)的臨床應(yīng)用，ARF的死亡率已由50降至10左右，死因主要為化膿性感染。Berns等認(rèn)為，肌紅蛋白分子量是17 800，血液濾過(guò)比其它血液凈化方式能更有效的清除肌紅蛋白，超濾液中可以測(cè)到肌紅蛋白，血液濾過(guò)可以預(yù)防擠壓綜合征患者發(fā)生ARF及其它橫紋肌溶解所致的ARF。但是，Wakahayae及Shigenoto報(bào)告，不管采用何種血液凈化方式和腎功能狀態(tài)如何，肌紅蛋白水平都可以迅速下降，提示肌紅蛋白存在腎外代謝

25、途徑。擠壓綜合征屬高分解代謝，CBP應(yīng)該早期充分透析，糾正電解質(zhì)、酸堿失衡，加強(qiáng)營(yíng)養(yǎng)支持，堿化尿液。另外，積極處理原發(fā)病，清除創(chuàng)傷擠壓的壞死組織。糾正高鉀血癥也非常重要。 心臟手術(shù)后心臟手術(shù)患者在術(shù)前多伴有慢性缺血導(dǎo)致的臟器損傷，術(shù)后常并發(fā)前負(fù)荷過(guò)多、急性腎功能損傷以及高鉀血癥和/或代謝性酸中毒等，氮質(zhì)血癥和液體過(guò)負(fù)荷是常見(jiàn)并發(fā)癥。積極地接受CRRT(CVVH、CVVHDF、CVVHD)治療的患者，有助于代謝和血容量穩(wěn)定而不引起血液動(dòng)力學(xué)的紊亂102。若并發(fā)ARF，其死亡率極高，盡快接受CVVH治療的存活患者，腎臟功能可完全恢復(fù)?；仡櫺苑菍?duì)照研究發(fā)現(xiàn)，心臟外科手術(shù)合并急性腎衰患者(血濾前肌酐水平295mmol/L，血濾開(kāi)始平均間隔為50小時(shí)，血濾持續(xù)時(shí)間平均6.4天)出院前平均肌酐168mmol/L，有2.2%的患者需要長(zhǎng)期腎臟替代治療103，CPB(體外循環(huán))術(shù)后出現(xiàn)尿量開(kāi)始減少、液體過(guò)負(fù)荷等需要盡早