AKI的診治-KDIGO指南解讀-課件

AKI的診治KDIGO指南解讀AsaGlobalLeader:現(xiàn)任主席Kai-UweEckardt,MDGarabedEknoyan,MDNorbertLameire,MD成員來(lái)自19個(gè)國(guó)家非營(yíng)利性團(tuán)體它的使命·

來(lái)自北美、南美、歐洲、非洲、亞洲等19個(gè)國(guó)家的腎臟病學(xué)家，由6人組成的理事會(huì)負(fù)責(zé)運(yùn)營(yíng)?！DIGO指定美國(guó)腎臟病基金會(huì)(NationalKidneyFoundation，NKF)作為其管理機(jī)構(gòu)。采取了公開(kāi)和透明的制度，發(fā)表具有科學(xué)性、系統(tǒng)性、實(shí)用性、代表性、公正性和權(quán)威性的指南用于指導(dǎo)臨床實(shí)踐。·

通過(guò)促進(jìn)和協(xié)調(diào)世界范圍內(nèi)的大合作，整合已有的相關(guān)工作，制定出適用于CKD患者的臨床實(shí)踐指南，并在世界不同地區(qū)加以推廣，達(dá)到改善全球腎臟疾病患者醫(yī)療水準(zhǔn)和預(yù)后的目的。2003年KDIGO成立2008年慢性腎臟疾病中丙型肝炎的臨床實(shí)踐指南2009年慢性腎臟病---礦物質(zhì)和骨異常診斷,評(píng)價(jià)，預(yù)防和治療的臨床實(shí)踐指南2009年KDIGO臨床實(shí)踐指南：腎移植受者的診治2011年KDIGO臨床指南：腎小球腎炎已頒布KDIGO國(guó)際指南2012年急性腎損傷指南AKI工作組成員WorkGroupCo-ChairsJohnA.Kellum,MD,FACP,FCCM,FCCP Pittsburgh,PANorbertLameire,MD,PhD Ghent,BelgiumWorkGroupPeterAspelin,MD,PhD Stockholm,SwedenRashadS.Barsoum,MD,FRCP,FRCPE Cairo,EgyptEmmanuelA.Burdmann,MD,PhD S?oJosédoRioPreto,BrazilStuartL.Goldstein,MD Houston,TXCharlesA.Herzog,MD Minneapolis,MNMichaelJoannidis,MD Innsbruck,AustriaAndreasKribben,MD Essen,GermanyWorkGroup

AndrewS.Levey,MD Boston,MAAlisonM.MacLeod,MBChB,MD,FRCP Aberdeen,UnitedKingdomRavindraL.Mehta,MD,FACP,FASN,FRCP SanDiego,CAPatrickT.Murray,MD,FASN,FRCPI Dublin,IrelandSaraladeviNaicker,MBChB,MRCP,PhD Johannesberg,SouthAfricaStevenM.Opal,MD Pawtucket,RIFranzS.Schaefer,MD Heidelberg,GermanyMietSchetz,MD,PhD Leuven,BelgiumShigehikoUchino,MD Tokyo,Japan專業(yè)人員評(píng)估證據(jù)力度指南推薦強(qiáng)度QualityofevidenceA－HighB－ModerateC－LowD－VerylowStrengthofrecommendationLevel1－strongLevel2－weakordiscretionary推薦等級(jí)含義患者臨床醫(yī)生政府部門(mén)1級(jí)“推薦”recommend絕大多數(shù)患者將按照推薦的要求絕大多數(shù)患者給予推薦的治療方案推薦意見(jiàn)可用作制定政策參考2級(jí)“建議”suggest”多數(shù)患者可按照建議來(lái)做，但還有很多人不需要有多種不同的方案可供不同患者選擇。強(qiáng)調(diào)根據(jù)患者的要求和意愿制定治療方案需要與相關(guān)利益方在進(jìn)行進(jìn)一步的協(xié)商分級(jí)證據(jù)標(biāo)準(zhǔn)A級(jí)（高質(zhì)量）試驗(yàn)結(jié)果和真實(shí)情況非常接近B級(jí)（中等質(zhì)量）：試驗(yàn)結(jié)果與真實(shí)情況可能較接近，不排除存在偏差之可能C級(jí)（低質(zhì)量）：試驗(yàn)結(jié)果與真實(shí)情況之間可能存在較大偏差D級(jí)（極低質(zhì)量）：試驗(yàn)結(jié)果本身多屬推測(cè)，與實(shí)際情況相差甚遠(yuǎn)指南推薦強(qiáng)度內(nèi)容Section1:介紹、背景、方法Section2:定義和分級(jí),風(fēng)險(xiǎn)評(píng)估,一般管理,臨床應(yīng)用Section3:AKI的預(yù)防與治療Section4:造影劑誘導(dǎo)AKISection5:AKI腎臟替代治療RIFLECriteriaforAcuteKidneyInjuryRiskInjuryFailureLossESRDIncreasedcreatininex1.5EndStageRenalDiseaseScrtCriteria*UrineOutputCriteriaUO<.3ml/kg/hx24

hrorAnuriax12hrsUO<.5ml/kg/hx12hrUO<.5ml/kg/hx6hrIncreasedcreatininex2Increasecreatininex3orcreatinine34mg/dl(Acuteriseof30.5mg/dl)

HighSensitivityHighSpecificityPersistentARF**=completelossofrenalfunction>4

weekswww.ADQI.netOliguriaCritCare2004,8:R204-12RIFLEhasbeenvalidatedin>500,000ptsHospitalandICUbasedstudiesRecentstudies120,123patientsin57ICUsinAustralia(Bagshawetal)36.1%developedAKIHospMortality:R:17.9%,I:27.7%,F:33.2%41,972patientsin22ICUsinEurope(Ostermannetal.)35.8%developedAKIHospMortality:R:20.9%,I:45.6%,F:56.8%PopulationbasedstudiesNorthernScotland(pop523,390)(Alietal.)AKIincidence2147pmp(16%CKD)BycomparisontheincidenceofacuteMIinUSisapproximately2667pmpR(I)I(II)F(III)Increasedcreatininex1.5OR>0.3mg/dlUO<.3ml/kg/hx24

hrorAnuriax12hrsUO<.5ml/kg/hx12hrUO<.5ml/kg/hx6hrIncreasedcreatininex2Increasecreatininex3orcreatinine34mg/dl(Acuteriseof30.5mg/dl)

ModifiedRIFLEasProposedbyAKINRRTStarted必須在48小時(shí)內(nèi)達(dá)到標(biāo)準(zhǔn)JoannidisM,etal:IntCareMed2009;35:1692-17023%10%CHAPTER2.1:AKI定義和分級(jí)2.1.1:Acutekidneyinjury(AKI)isdefinedasanyofthefollowing(NotGraded):IncreaseinSCrby≥0.3mg/dlwithin48hours;orIncreaseinSCrto≥1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithinprior7days;orUrinevolume<0.5ml/kg/hfor6hours.CHAPTER2.1:AKI定義和分級(jí)2.1.2:AKIisstagedforseverityaccordingtothefollowingcriteria(NotGraded):CHAPTER2.1:2.1:AKI定義和分級(jí)2.1.3:ThecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)Conceptualframeworkforrisk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)ICU對(duì)腎功能的關(guān)注

既要“已病圖治”又要“未病先防”腎功能不全患者腎衰患者未病有高危因素患者輕癥患者，需防止加重腎損害已病患者，哪些藥物更合理？存在高危因素患者，避免使用可能腎損害藥物更科學(xué)？AKI的預(yù)防3.1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)可控因素常用的腎毒性藥物氨基糖苷類非甾體類抗炎藥萬(wàn)古霉素兩性霉素B造影劑….？避免腎毒性藥物聯(lián)合使用萬(wàn)古霉素說(shuō)明書(shū)舉例腎臟損傷患者保護(hù)腎余功能腎小球?yàn)V過(guò)率下降50%，Scr才上升，Ccr評(píng)價(jià)腎功能更為敏感；Ccr小于70的患者根據(jù)說(shuō)明書(shū)嚴(yán)格調(diào)整劑量以及盡可能選擇非腎損藥物根據(jù)說(shuō)明書(shū)監(jiān)測(cè)血藥濃度關(guān)注腎臟各項(xiàng)指標(biāo)，一旦異常，及時(shí)干預(yù)CHAPTER2.3:AKI

或高危病人

的一般管理2.3.1:EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)

2.3.2:MonitorpatientswithAKIwithmeasurementsofserumcreatinineandurineoutputtostagetheseverity,accordingtoRecommendation2.1.2.(NotGraded)2.3.3:ManagepatientswithAKIaccordingtothestageandcause[seenextslide].(NotGraded)AKI發(fā)生后的管理策略Stage-basedmanagementofAKI:Shadingofboxesindicatespriorityofaction—solidshadingindicatesactionsthatareequallyappropriateatallstageswhereasgradedshadingindicatesincreasingpriorityasintensityincreases.3.3造影劑腎病評(píng)估危險(xiǎn)因素評(píng)估容量狀態(tài)造影前水化對(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

目前無(wú)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)袢利尿劑反對(duì)MehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425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Mathur,CritCareMed1999Murphy,NEnglJMed2001Schusterman,AmJMed1993Landoni,AmJKidneyDis2007需多中心隨機(jī)對(duì)照研究證實(shí)營(yíng)養(yǎng)支持

個(gè)體評(píng)估(1D)總熱卡25-35kcal/kg/day氨基酸≤1.7g/kg/day微量元素和水溶性維生素(1C)AKI的腎臟替代治療血管通路臨時(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)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CHAPTER5.6:AKI腎替代治療方式選擇5.6.1:UsecontinuousandintermittentRRTascomplementarytherapiesinAKIpatients.(NotGraded)IHDorCRRT?ORBagshawetal.CCM2008;36:610-7CHAPTER5.6:AKI

腎替代治療方式選擇5.6.2:WesuggestusingCRRTratherthanstandardintermittentRRT,forhemodynamicallyunstablepatients.(2B)5.6.3:WesuggestusingCRRT,ratherthanintermittentRRT,forAKIpatientswithacutebraininjuryorothercausesofincreasedintracranialpressureorgeneralizedbrainedema.(2B)

CochraneDatabaseSystRev2007:CD003773.Hemodynamicinstability:RR0.48;0.10-2.28;n=205)Hypotension:(RR0.92;95%CI0.72-1.16;n=514).Meanarterialpressureattheendofthetreatment:CRRTvsIHD(meandeviation5.35;95%CI1.41-9.29;n=112)Numberofpatientsrequiringescalationofvasopressors:CRRTvsIHD(RR0.49;95%CI0.27-0.87;n=149)顱內(nèi)高壓患者Dialysisdisequilibriumresultsfromtherapidremovalofsolutes,resultinginintracellularfluidshifts.SmallobservationaltrialsandcasereportsinpatientswithintracranialpressuremonitoringindeedreportedincreasesinintracranialpressurewithIHD.Bagshawetal.BMCNephrol2004;5:9Linetal.ActaNeurochirSuppl2008;101:141-144.CTscanmeasuredbraindensityshowsincreaseofbrainwatercontentafterIHD,whereasnosuchchangeswereobservedafterCRRT.Roncoetal.JNephrol1999;12:173-178.CHAPTER5.7:RRT的置換液選擇

5.7.1:Wesuggestusingbicarbonate,ratherthanlactate,asabufferindialysateandreplacementfluidforRRTinpatientswithAKI.(2C)5.7.2:Werecommendusingbicarbonate,ratherthanlactate,asabufferindialysateandreplacementfluidforRRTinpatientswithAKIandcirculatoryshock.(1B)

CHAPTER5.8:RRT的治療劑量5.8.3:WerecommenddeliveringaKt/Vof3.9perweekwhenusingintermittentorextendedRRTinAKI.(1A)