KDIGO急性腎損傷指南解讀

KDIGO急性腎損傷指南解讀1精選pptKDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryKidneyinter.Suppl.2021;2:1–1382精選pptGRADE系統(tǒng)3精選ppt總推薦條目87條未分級26條29.9%2級39條63.9%1級22條36.1%1A:914.8%1B:1016.4%1C:34.9%2A:23.3%2B:1016.4%2C:2032.8%2D:711.5%4精選ppt內(nèi)容IntroductionandMethodologyAKIDefinitionPreventionandTreatmentofAKIContrast-inducedAKIDialysisInterventionsforTreatmentofAKI5精選ppt符合以下任何一條即可診斷1.IncreaseinSCrby≥0.3mg/dl(≥26.5lmol/l)within48hours2.IncreaseinSCrto≥1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days3.Urinevolume<0.5ml/kg/hfor6hours.AKI診斷(NotGraded)6精選pptStageSerumcreatinineUrineoutput11.5–1.9timesbaselineOR<0.5ml/kg/hfor≥0.3mg/dl(≥26.5mmol/l)increase6–12hours22.0–2.9timesbaseline<0.5ml/kg/hfor≥12hours33.0timesbaselineORIncreaseinserumcreatinineto<0.3ml/kg/hfor

≥4.0mg/dl(≥353.6mmol/l)≥24hoursORORInitiationofrenalreplacementtherapyAnuriafor≥12hoursOR,Inpatients<18years,decreaseineGFRto<35ml/minper1.73m2AKI分級(NotGraded)7精選pptThecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)SelectedcausesofAKIrequiringimmediatediagnosisandspecifictherapiesRecommendeddiagnostictestsDecreasedkidneyperfusionVolumestatusandurinarydiagnosticindicesAcuteglomerulonephritis,vasculitis,Urinesedimentexamination,interstitialnephritis,thromboticserologictestingandMicroangiopathyhematologictesting

UrinarytractobstructionKidneyultrasound8精選pptWerecommendthatpatientsbestratifiedforriskofAKIaccordingtotheirsusceptibilitiesandexposures.(1B)ManagepatientsaccordingtotheirsusceptibilitiesandexposurestoreducetheriskofAKI.(NotGraded)TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)9精選pptExposuresSusceptibilitiesSepsisDehydrationorvolumedepletionCriticalillnessAdvancedageCirculatoryshockFemalegenderBurnsBlackraceTraumaCKDCardiacsurgery(especiallyChronicdiseases(heart,lung,liver)withCPB)MajornoncardiacsurgeryDiabetesmellitusNephrotoxicdrugsCancerRadiocontrastagentsAnemiaPoisonousplantsandanimalsCausesofAKI:exposuresandsusceptibilitiesfornon-specificAKI10精選pptEvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)MonitorpatientswithAKIwithmeasurementsofSCrandurineoutputtostagetheseverity,accordingtoRecommendation.(NotGraded)ManagepatientswithAKIaccordingtothestageandcause.(NotGraded)11精選ppt12精選ppt13精選pptAKI時RRT治療時機InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.(NotGraded)Considerthebroaderclinicalcontext,thepresenceofconditionsthatcanbemodifiedwithRRT,andtrendsoflaboratorytests—ratherthansingleBUNandcreatininethresholdsalone—whenmakingthedecisiontostartRRT.(NotGraded)14精選pptPotentialapplicationsforRRTApplicationsCommentsRenalreplacementThisisthetraditional,prevailingapproachbasedonutilizationofRRTwhenthereislittleornoresidualkidneyfunction.Life-threateningindicationsNotrialstovalidatethesecriteria.HyperkalemiaDialysisforhyperkalemiaiseffectiveinremovingpotassium;however,itrequiresfrequentmonitoringofpotassiumlevelsandadjustmentofconcurrentmedicalmanagementtopreventrelapses.AcidemiaMetabolicacidosisduetoAKIisoftenaggravatedbytheunderlyingcondition.CorrectionofmetabolicacidosiswithRRTintheseconditionsdependsontheunderlyingdiseaseprocess.PulmonaryedemaRRTisoftenutilizedtopreventtheneedforventilatorysupport;however,itisequallyimportanttomanagepulmonaryedemainventilatedpatients.Uremiccomplications(pericarditis,bleeding,etc.)IncontemporarypracticeitisraretowaittoinitiateRRTinAKIpatientsuntilthereareuremiccomplications15精選pptPotentialapplicationsforRRTApplicationsCommentsNonemergentindicationsSolutecontrolBUNreflectsfactorsnotdirectlyassociatedwithkidneyfunction,suchascatabolicrateandvolumestatus.SCrisinfluencedbyage,race,musclemass,andcatabolicrate,andbychangesinitsvolumeofdistributionduetofluidadministrationorwithdrawal.FluidremovalFluidoverloadisanimportantdeterminantofthetimingofRRTinitiation.Correctionofacid-baseAbnormalitiesNostandardcriteriaforinitiatingdialysisexist.16精選pptPotentialapplicationsforRRTApplicationsCommentsRenalsupportThisapproachisbasedontheutilizationofRRTtechniquesasanadjuncttoenhancekidneyfunction,modifyfluidbalance,andcontrolsolutelevels.VolumecontrolFluidoverloadisemergingasanimportantfactorassociatedwith,andpossiblycontributingto,adverseoutcomesinAKI.RecentstudieshaveshownpotentialbenefitsfromextracorporealfluidremovalinCHF.Intraoperativefluidremovalusingmodifiedultrafiltrationhasbeenshowntoimproveoutcomesinpediatriccardiacsurgerypatients.NutritionRestrictingvolumeadministrationinthesettingofoliguricAKImayresultinlimitednutritionalsupportandRRTallowsbetternutritionalsupplementation.DrugdeliveryRRTsupportcanenhancestheabilitytoadministerdrugswithoutconcernsaboutconcurrentfluidaccumulation.RegulationofPermissivehypercapnicacidosisinpatientswithlunginjurycanbecorrectedacid-basewithRRT,withoutinducingfluidoverloadandhypernatremia.andelectrolytestatusSoluteChangesinsoluteburdenshouldbeanticipated(e.g.,tumorlysismodulationsyndrome).Althoughcurrentevidenceisunclear,studiesareongoingtoassesstheefficacyofRRTforcytokinemanipulationinsepsis.17精選ppt

AKI時停用RRT指征DiscontinueRRTwhenitisnolongerrequired,eitherbecauseintrinsickidneyfunctionhasrecoveredtothepointthatitisadequatetomeetpatientneeds,orbecauseRRTisnolongerconsistentwiththegoalsofcare.(NotGraded)Wesuggestnotusingdiureticstoenhancekidneyfunctionrecovery,ortoreducethedurationorfrequencyofRRT.(2B)18精選ppt抗凝治療InapatientwithAKIrequiringRRT,basethedecisiontouseanticoagulationforRRTonassessmentofthepatient’spotentialrisksandbenefitsfromanticoagulation.(NotGraded)WerecommendusinganticoagulationduringRRTinAKIifapatientdoesnothaveanincreasedbleedingriskorimpairedcoagulationandisnotalreadyreceivingsystemicanticoagulation.(1B)19精選pptForpatientswithoutanincreasedbleedingriskorimpairedcoagulationandnotalreadyreceivingeffectivesystemicanticoagulation,wesuggestthefollowing:ForanticoagulationinintermittentRRT,werecommendusingeitherunfractionatedorlow-molecular-weightheparin,ratherthanotheranticoagulants.(1C)ForanticoagulationinCRRT,wesuggestusingregionalcitrateanticoagulationratherthanheparininpatientswhodonothavecontraindicationsforcitrate.(2B)ForanticoagulationduringCRRTinpatientswhohavecontraindicationsforcitrate,wesuggestusingeitherunfractionatedorlow-molecular-weightheparin,ratherthanotheranticoagulants.(2C)抗凝治療20精選pptForpatientswithincreasedbleedingriskwhoarenotreceivinganticoagulation,wesuggestthefollowingforanticoagulationduringRRT:Wesuggestusingregionalcitrateanticoagulation,ratherthannoanticoagulation,duringCRRTinapatientwithoutcontraindicationsforcitrate.(2C)WesuggestavoidingregionalheparinizationduringCRRTinapatientwithincreasedriskofbleeding.(2C)抗凝治療21精選pptInapatientwithheparin-inducedthrombocytopenia(HIT),allheparinmustbestoppedandwerecommendusingdirectthrombininhibitors(suchasargatroban)orFactorXainhibitors(suchasdanaparoidorfondaparinux)ratherthanotherornoanticoagulationduringRRT.(1A)InapatientwithHITwhodoesnothavesevereliverfailure,wesuggestusingargatrobanratherthanotherthrombinorFactorXainhibitorsduringRRT.(2C)抗凝治療22精選ppt23精選ppt血管通路WesuggestinitiatingRRTinpatientswithAKIviaanuncuffednontunneleddialysiscatheter,ratherthanatunneledcatheter.(2D)WhenchoosingaveinforinsertionofadialysiscatheterinpatientswithAKI,considerthesepreferences(NotGraded):*Firstchoice:rightjugularvein;*Secondchoice:femoralvein;*Thirdchoice:leftjugularvein;*Lastchoice:subclavianveinwithpreferenceforthedominantside.24精選pptWerecommendusingultrasoundguidancefordialysiscatheterinsertion.(1A)Werecommendobtainingachestradiographpromptlyafterplacementandbeforefirstuseofaninternaljugularorsubclaviandialysiscatheter.(1B)WesuggestnotusingtopicalantibioticsovertheskininsertionsiteofanontunneleddialysiscatheterinICUpatientswithAKIrequiringRRT.(2C)Wesuggestnotusingantibioticlocksforpreventionofcatheter-relatedinfectionsofnontunneleddialysiscathetersinAKIrequiringRRT.(2C)血管通路25精選ppt濾器選擇WesuggesttousedialyzerswithabiocompatiblemembraneforIHDandCRRTinpatientswithAKI.(2C)26精選pptRRT模式選擇UsecontinuousandintermittentRRTascomplementarytherapiesinAKIpatients.(NotGraded)WesuggestusingCRRT,ratherthanstandardintermittentRRT,forhemodynamicallyunstablepatients.(2B)WesuggestusingCRRT,ratherthanintermittentRRT,forAKIpatientswithacutebraininjuryorothercausesofincreasedintracranialpressureorgeneralizedbrainedema.(2B)27精選pptTypicalsettingofdifferentRRTmodalitiesforAKI(for70-kgpatient)28精選pptTheoreticaladvantagesanddisadvantagesofC