crrt影響aki殘余腎功能嗎？課件

CRRT影響AKI殘余腎功能嗎？OutlineAKI的流行病學殘余腎功能的概念及臨床意義CRRT對殘余腎功能的影響及可能機制小結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-requiringARFbycalendaryearProspectiveobservationalstudySeptember2000toDecember2001at54hospitalsin23countriesOf29269criticallyillpatientsadmittedduringthestudyperiod,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:hazardratioof2.7EpidemiologyofAKIBloodPurif2011;31:159–171MulticenterItalianStudyRIFLE-BasedDataOutlineAKI的流行病學殘余腎功能的概念及臨床意義CRRT對殘余腎功能的影響及可能機制小結殘余腎功能(ResidualrenalfunctionRRF)定義：是指腎臟受到損傷后健存腎單位的殘留功能，包括清除毒素、調節(jié)水電解質和酸堿平衡以及多種內(nèi)分泌功能殘余腎功能與AKI長期預后正相關IntensityofRenalSupport不改善AKI病死率NEnglJMed2008;359:7-20.NEnglJMed2009;361:1627-38.Onceanorganisinjured

TryandassistafailingorganbytreatingtheunderlyingcauseTrytoforcethatorgantoworkhardermaynotbethebestapproachResttheinjuredorganshouldbesensibleAvoidsignificantadverseevents

CriticalCare2012,16:317OutlineAKI的流行病學殘余腎功能的概念及臨床意義CRRT對殘余腎功能的影響及可能機制小結CRRT特點穩(wěn)定的血流動力學持續(xù)穩(wěn)定的控制氮質血癥和水電/酸堿平衡能夠不斷清除循環(huán)中的毒素或中分子物質按需提供營養(yǎng)補充和藥物治療CRRTvsIRRTIHDPDCRRTHemodynamicstability…+++Osmopressurestability…++++Fluidremoval++++++Correctionofacidosis++++++UnlimitedPN/EN……++ClearancesSmallsolutes(<500d)++++++Largesolutes(>500d)…++++Mediatorremoval……++?Accessmorbidity++++Anticoagulationneeds+…+Simplicity++++++ComparedtoIRRT,CRRTcanhelptoraiseMAPTheCochraneLibrary2008,Issue3CRRTdecreasestherequiringofpressorTheCochraneLibrary2008,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腎功能恢復的影響

－CRRT促進腎功能恢復CritCareMed2003;31:449–455CRRT：腎功能恢復1218patientsforARFin54ICUin23countriesIntJArtifOrgans2007;30(4):281-292腎功能恢復CRRT能促進腎功能恢復DesignRetrospectivecohortstudy32SwedishICUs2,202patientswithARF(excludeESRD)IntensiveCareMed.2007,33:773–780VeryhighrateofintradialytichypotensionintheIHDgroup–comparedtoCRRT/SLEDtreatments:TwiceasmanyIHDtreatmentsrequiredincreasedvasopressorsupportSixtimesasmanyIHDtreatmentshadtobestoppedRenalrecoveryratewaslowerthanexpected(~50%at28days)–possiblyrelatedtohypotensionduringIHDATNTrial:ImportantResultsDebateofrecoveryofrenalfunction

--ResultsofMetaanalysisMetaanalysisshowsnodifferenceinmortalityandchronicdialysisdependenceofpatientswithARFamongCRRT,IRRTorSLEDJAMA.2008;299(7):793-805SafetyCRRTRequirecontinuousanticoagulationTimeislongerIRRTRapidfluidandsoluteremovelBleedingDepletionofnutrientsInfectionHypotensionArrhythmiaHypothermiaismorefrequentduringCRRT,othercomplicationsaresimilarLancet2006;368:379–85OutlineAKI的流行病學殘余