KDIGO-AKI诊疗指南

急性肾损伤诊疗指南解读 KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury 2012 赵良斌 KDIGO KidneyDiseaseImprovingGlobalOutcomes 2012 KDIGO指南解读 急性肾损伤 AKI 与急性肾衰竭 ARF 国际肾脏病和急救医学界将ARF改为急性肾损伤 AcuteKidneyInjury AKI AKI覆盖的肾损伤 WarnockDG JAmSocNephrol16 3149 3150 2006BiesenWVetal CJASN 2006 AboutAKIguideline ADQI 2002 RIFLEAKIN 2005 modifieddefinitionandstagingsystemKDIGO 2011 FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI 2011UKRenalAssociationFinalVersion08 03 11AKIguidline KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury AKI流行病学现状 患病率 1 社区 7 1 医院 人群发病率 486 630pmp yAKI需要RRT发病率 22 203pmp y医院获得AKI死亡率 10 80 合并多脏器功能衰竭死亡率 50 需要RRT治疗者死亡率 高达80 指南推荐强度 指南推荐强度 Guideline1 AKI的定义与分期 符合以下情况之一者即可被诊断为AKI 48小时内Scr升高超过26 5 mol L 0 3mg dl Scr升高超过基线1 5倍 确认或推测7天内发生 尿量 0 5ml kg h 且持续6小时以上 单用尿量改变作为判断标准时 需要除外尿路梗阻及其它导致尿量减少的原因 采用KDIGO推荐的定义和分期标准 AKI分期标准 指南推荐血清肌酐和尿量仍然作为AKI最好的标志物 1B RIFLE分级 2002年急性透析质量倡议组 ADQI 制定了ARF的RIFLE分级诊断标准 BellomoR etal CritCare2004 8 R204 R212 ConceptualmodelforAKI Guideline2 临床评估 2 1详细的病史采集和体格检查有助于AKI病因的判断 1A 2 224小时之内进行基本的检查 包括尿液分析和泌尿系超声 怀疑有尿路梗阻者 1A Chapter2 2 Riskassessment Chapter2 2 Riskassessment AKIisdefinedasanyofthefollowing NotGraded AKIisdefinedasanyofthefollowing NotGraded KIncreaseinSCrbyX0 3mg dl X26 5lmol l within48hours orKIncreaseinSCrtoX1 5timesbaseline whichisknownorpresumedtohaveoccurredwithintheprior7days orKUrinevolumeo0 5ml kg hfor6hours TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI NotGraded Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse NotGraded EvaluatepatientswithAKIpromptlytodeterminethecause withspecialattentiontoreversiblecauses NotGraded hecauseofAKIshouldbedeterminedwheneverpossible NotGraded DefinitionandstagingofAKI OverviewofAKI CKD andAKD OverlappingovalsshowtherelationshipsamongAKI AKD andCKD AKIisasubsetofAKD BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD IndividualswithoutAKI AKD orCKDhavenoknownkidneydisease NKD notshownhere AKD acutekidneydiseasesanddisorders AKI acutekidneyinjury CKD chronickidneydisease AKDacutekidneydiseasesanddisorder 符合以下任何一项AKI 符合AKI定义3个月内在原来基础上 GFR下降35 或Scr上升50 GFR 60ml min 1 73m2 3个月肾损伤 3个月 AKI CKD AKD Guideline3 PreventionandTreatmentofAKI 3 1评估危险因素 1B 年龄 75岁CKD eGFR 60ml min 1 73m2心力衰竭动脉粥样硬化性周围血管病变肝脏疾病糖尿病肾毒性药物的使用低血容量感染3 2评估容量状态后适当补液 1B HIGHRISK 3 3造影剂肾病 3 4继发于横纹肌溶解的AKI给予0 9 氯化钠和碳酸氢钠扩容 1B 对具CI AKI高风险者 建议采用等渗或低渗造影剂建议口服或静脉使用N 乙酰半胱氨酸 NAC 及等渗晶体预防CI AKI推荐使用等渗氯化钠或碳酸氢钠静脉扩容以预防CI AKI Guideline4 AKI的治疗 一般治疗 1A Stage basedmanagementofAKI Chapter2 3 EvaluationandgeneralmanagementofpatientswithandatriskforAKI 补液治疗 Intheabsenceofhemorrhagicshock wesuggestusingisotoniccrystalloidsratherthancolloids albuminorstarches asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI 2B Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith oratriskforAKI 1C Wesuggestusingprotocol basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh riskpatientsintheperioperativesetting 2C orinpatientswithsepticshock 2C 补液治疗 低血容量者 重复小剂量补液 250ml晶体液 胶体液 密切监测CVP和尿量监测乳酸和碱剩余水平严重脓毒血症者 慎用高分子量羟乙基淀粉 药物治疗 1B 多脏器功能衰竭药代动力学改变 分布容积 清除 与蛋白结合 需要调整药物剂量 目前无特殊的药物用于治疗继发于低灌注损伤 脓毒血症的AKI 1B 袢利尿剂 against MehtaRL PascualMT SorokoSetal Diuretics mortality andnonrecoveryofrenalfunctioninacuterenalfailure JAMA2002 288 2547 2553HoKM SheridanDJ Meta analysisoffrusemidetopreventortreatacuterenalfailure BMJ2006 333 7565 420 425 Chapter3 4 TheuseofdiureticsinAKI WerecommendnotusingdiureticstopreventAKI 1B WesuggestnotusingdiureticstotreatAKI exceptinthemanagementofvolumeoverload 2C Effectoffurosemidevs controlonall causemortality ReprintedfromHoKM PowerBM Benefitsandrisksoffurosemideinacutekidneyinjury Anaesthesia2010 65 283 293withpermissionfromJohnWileyandSons193 Effectoffurosemidevs controlonneedforRRT ReprintedfromHoKM PowerBM Benefitsandrisksoffurosemideinacutekidneyinjury Anaesthesia2010 65 283 293withpermissionfromJohnWileyandSons193 TheuseofdiureticsinAKI Atpresent thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident 甘露醇 mannitolisnotscientificallyjustifiedinthepreventionofAKI Vasodilatortherapy dopamine fenoldopam andnatriureticpeptides Werecommendnotusinglow dosedopaminetopreventortreatAKI 1A Wesuggestnotusingfenoldopam 非诺多巴 topreventortreatAKI 2C Wesuggestnotusingatrialnatriureticpeptide ANP toprevent 2C ortreat 2B AKI Effectoflow dosedopamineonmortality ReprintedfromFriedrichJO AdhikariN HerridgeMSetal Meta analysis low dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath AnnInternMed2005 142 510 524withpermissionfromAmericanCollegeofPhysicians212 多巴胺 不建议 FriedrichJO AdhikariN HerridgeMS Meta analysis low dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath AnnInternMed2005 142 510 524 降低肾灌注 Lauschke KidneyInt2006 导致心律失常 Schenarts CurrentSurgery2006 加重心肌 肠道缺血缺氧 Schenarts CurrentSurgery2006 非诺多巴 不建议 选择性多巴胺A1受体激动剂 在降低全身血管阻力的同时增加肾血流量 RESEARCHRECOMMENDATION WerecommendfurthertrialsofANPatdosesbelow0 1mg kg min forthepreventionortreatmentofAKI ThereisapossibilitythatANPmightbeeffectiveifitisgivenatalowerdose 0 01 0 05mg kg min inpatientsprophylacticallyorwithearlyAKI andduringalongerperiodthaninpreviouslargestudie Glycemiccontrolandnutritionalsupport Incriticallyillpatients 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 Growthfactorintervention Werecommendnotusingrecombinanthuman rh IGF 1topreventortreatAKI 1B humanIGF 1 重组人胰岛素样生长因子1 Preventionofaminoglycoside andamphotericin relatedAKI Wesuggestnotusingaminoglycosidesforthetreat 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 andamphotericin relatedAKI Wesuggestusinglipidformulationsofampho tericinBratherthanconventionalformulationsofamphotericinB 2A Inthetreatmentofsystemicmycosesorparasiticinfections werecommendusingazoleantifungalagentsand ortheechinocandinsratherthanconventionalamphotericinB ifequaltherapeuticefficacycanbeassumed 1A OthermethodsofpreventionofAKIinthecriticallyill Wesuggestthatoff pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT 2C WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension 2D Werecommendnotusingoralori v NACforpreventionofpostsurgicalAKI 1A CI AKI 预防对比剂急性肾损害 Guideline5 医疗资源合理分配 多学科参与AKI指南制定肾科医生会诊提供专科意见合理的转诊方案密切监护治疗肾脏科与ICU医生协作 Whentorequestarenalreferral Guideline6 RRT模式的选择 建议个体化治疗 1B Kanagasundaram 2007 Guideline7 透析器和透析液的选择 透析器 合成膜透析器 1B 改良纤维素膜透析器 1B 透析液 首选碳酸氢钠透析液 置换液 1C 透析液微生物的控制 Guideline8 血管通路 临时建立静脉 静脉通路 1A 选择足够长度的透析导管以降低再循环率 1B 置管部位和导管类型需根据患者的病情选择 2C 由经验丰富的医生负责置管 1A 实时超声导引有助于置管 1D 对有进展至CKD4 5期风险的患者 尽量避免行锁骨下静脉置管 保护患者的血管资源 1D Guideline8 血管通路 保护非优势侧的上肢血管 2C 定期更换临时导管以降低感染的风险 1C 颈内静脉 3周股静脉 1周 3周 建议用皮下隧道导管导管仅限于RRT治疗时使用 1D 以预防感染 Guideline9 体外抗凝 根据患者病情和RRT模式制定抗凝治疗方案 1C 推荐枸橼酸局部抗凝降低出血风险 2C 具有出血风险的患者可选择前列环素抗凝 但会引起血流动力学不稳定 2C 具有高出血风险的患者可采取无抗凝剂 盐水冲洗的方法 但引起超滤量增加 透析效率下降及增加了透析膜破裂的风险 2C Guideline10 RRT处方 通过对RRT剂量的评估确保透析充分性 1A 每次 IHD 或每日 CRRT 评估透析剂量及充分性 1A 推荐伴有多器官功能衰竭的AKI患者行CRRT 后稀释法超滤率 25ml kg hr 前稀释法的持续性血液滤过相应的上调超滤率 1A 伴有多器官功能衰竭的AKI患者行间歇性血液透析治疗治疗时 必须达到单次透析URR 65 或eKt V 1 2 或者进行每日透析 1