齐鲁医学ICU中的血液净化指南之我见

1、ICU中的血液净化指南之我见12021/10/23 星期六ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions5622021/10/23 星期六IntroductionMethods of extracorporeal renal replacement therapy (RRT) have been used for the supportive treatment of AKI for over 60 years.CRRT for the critically ill patient wi

2、th ARF was introduced in 1977 by Kramer et al. Since then, many studies have reported on CRRT in the critically ill.Klin Wochenschr 1977;55:1121-1122.32021/10/23 星期六IntroductionBut for several reasons comparison among studies is difficult: Various treatment modalities have been applied in heterogene

3、ous populations. Differences in clinical setting and underlying molecular biological mechanisms that initiate and maintain ARF. Furthermore, more than 35 definitions of ARF.Practice patterns vary widely between individual centers.Up to now, there are no standard guidelines for the application of CRR

4、T in critically ill patients.Curr Opin Crit Care 2002;8:509-514.42021/10/23 星期六IntroductionThe RIFLE Classification for acute renal failure Crit Care 2004;8:R204-R212.52021/10/23 星期六IntroductionConclusions:More then 200 different definitions of ARF and about 90 RRT start criteria were reported. Olig

5、uria and RIFLE were the most frequent criteria used to define ARF. RIFLE criteria might show a clinical impact on future daily practice and research.Different RRT techniques are available in most centers, but a general lack of treatment dose standardization is noted by our survey. Non-renal indicati

6、ons to RRT still need to find a definitive role in routine practice.Nephrol Dial Transplant (2006) 21: 69069662021/10/23 星期六In the past, the interaction between nephrology and intensive care was minimal.Today, there is continuous interaction with several moments of high interaction due to common pat

7、ients and complex syndromes, and much of the treatment of AKI has moved from the renal ward into ICUs. IntroductionContrib Nephrol. Basel, Karger, 2010 (166):1372021/10/23 星期六ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose or intensity of CRRT4Conclusions5682021/10/23 星期六Type of therapyCla

8、ssification of blood purification in critical care (BPCC) technologyPMX = polymyxin-B immobilized fiber; PMMA = polymethylmethacrylate; PAN = polyacrylonitrile; PEPA = polyether polymer alloyContrib Nephrol. Basel, Karger, 2010(166):112092021/10/23 星期六Type of therapyAs a continuous therapy, CRRT can

9、 be rapidly tailored to changes in a patients clinical condition during critical illnessBlood purification in critical careContrib Nephrol. Basel, Karger, 2010(166):1120HDF = hemodiafiltration102021/10/23 星期六Type of therapyThese advantages have contributed to the widespread uptake of CRRT as the fir

10、st-choice RRT in ICUs throughout Australia, Japan and Europe.In these regions, CRRT is usually initiated and managed within the ICU, with RRT being integrated with other aspects of the management of critical illnessNat. Rev. Nephrol. 2010:6:521529.112021/10/23 星期六Type of therapyIn north America, how

11、ever, traditional structures of ICU management favor an open-ICU approach:Within this model, RRT is usually prescribed by a nephrologist in the ICU and is initiated by a dialysis nurse In this environment, IHD has the advantage of requiring only daily or alternate-day attendance by the renal teamCon

12、versely, the relative labor costs of providing CRRT are increased, an effect that is compounded by the larger fixed costs and higher consumable requirements of CRRTThese logistic factors have led to a preference for IHD over CRRT being maintained in ICUs that use the north American.Nat. Rev. Nephrol

13、. 2010:6:521529.122021/10/23 星期六Type of therapyClinical studies of CRRT in the ICUThe diversity of clinical approaches to the treatment of AKI in the ICU is illustrated by the results of the BEST Kidney study,The multinational epidemiological study of RRT practice in the ICUStudy documented the trea

14、tment of AKI in 1,738 patients in 54 ICUs on five continentsNat. Rev. Nephrol. 2010:6:521529.132021/10/23 星期六Type of therapyBEST study resultsCRRT was the most common choice of initial RRT treatment, with 80% of patients on CRRT; IHD use was mostly restricted to ICUs in north and south America, wher

15、e it was used as initial therapy in 3040% of patients, while, by contrast, CRRT is used first in 100% of ICUs in Australia.Among patients receiving CRRT, however, marked variation in the modality, intensity, timing was observedMaking it difficult to compare outcomes between patients on CRRT and thos

16、e on IHDNat. Rev. Nephrol. 2010:6:521529.142021/10/23 星期六Type of therapyNat. Rev. Nephrol. 2010:6:521529.152021/10/23 星期六有些研究表明在ICU不稳定的患者中应用IHD也不会存在明显的问题, 有RCTs并没有显示出CRRT优于IHDType of therapyKidney Int 2009,76:422-427.BMC Nephrol 2010, 11:32.Nephrol Dial Transplant 2009, 24:512-518.Lancet 2006,368:37

17、9-385. 对于依赖血管活性药物的AKI患者，CRRT才是最适合的；依赖血管活性药物的AKI患者将来接受长期透析的几率CRRT 间断性治疗；AKI的急性期推荐应用CRRT，尤其是对于严重血流动力学不稳定、需大量清除液体以便于进行更有效药物治疗的患者。Crit Care Med 2008, 36:610-617.Kidney Int 2009,76:422-427.Nat Rev Nephrol 2010, 9:521-529.Clin Pharmacol Ther 2009, 86:562-565.目前共识：162021/10/23 星期六ContentsIntroduction1 Type

18、 of therapy2Timing of CRRT3Dose of CRRT4Conclusions56172021/10/23 星期六Timing of CRRTThe right time to start RRT is still a topic of debate.主要的原因的是：没有一个明确的、协商一致的AKI定义能够根据肾损伤程度对患者进行分级研究时很难获得同种类相同特征的患者组人群RIFLE和AKIN分级标准使对于AKI的研究向前迈进了一大步两种分级标准均能使临床医生警惕AKI的出现，进行早期干预Crit Care 2009, 13:211.182021/10/23 星期六Ti

19、ming of CRRTThere is significant variation in the timing of initiation of RRT, with up to two-fold differences in the reported values of BUN, creatinine, or urine output at RRT initiation.Clinical studies evaluating the timing of initiation of CRRT in critically ill patients192021/10/23 星期六Timing of

20、 CRRTIn the above-mentioned studies there is a clear trend toward a better outcome with earlier timing of RRT. In the absence of large RCTs comparing early to late initiation of RRT, no firm overall recommendations for timing of RRT can be made. 202021/10/23 星期六Timing of CRRT目前广为接受的Septic AKI开始RRT时机

21、，尤其是在septic shock 时：RIFLE injury stage (or AKIN stage 2) but consensus on this topic awaits results from large-scale RCTs.212021/10/23 星期六Timing of CRRT除AKI外，患者的一些其他情况也需要行早期RRT治疗：mainly pediatric, treated by ECMO for severe ARDS.Fluid overload definitely plays a role in timing, because CRRT proved s

22、uccessful in patients without AKI but refractory to diuretics. 治疗时机的标准在不断发展，包括：severity of organ dysfunction (SOFA score)；severity of AKI (RIFLE or AKIN stage)；fluid overload status； time from admission；biomarker use, etc.但他们在日常临床实践中的应用价值仍然需要评估Kidney Int 2010, 77:469-470.Kidney Int 2009, 76:1289-129

23、2J Am Soc Nephrol 2011, 22:810-820.222021/10/23 星期六Timing of CRRTWhen initiation of RRT is considered, it is important to realize that:the consequences of ureamic toxicity, metabolic acidosis and/or fluid overload are likely to be more severe in the critically ill patient. Moreover, renal function i

24、s unlikely to recover within a short period during persistent and severe failure of other organs. Furthermore, various inflammatory mediators are cleared by the kidney.232021/10/23 星期六Timing of CRRT最近的一项前瞻性研究和两项meta-analysis明确地支持early timingThe findings of these studies support earlier initiation of

25、 acute RRTIn the absence of new evidence from suitably-designed randomised trials, a definitive treatment recommendation cannot be made242021/10/23 星期六ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions56252021/10/23 星期六Dose or intensity of CRRT262021/10/23 星期六Dose or inten

26、sity of CRRT272021/10/23 星期六Dose or intensity of CRRTBoth the ATN and RENAL studies failed to detect any survival benefit from more-intensive RRT And no significant differences in mortality rates were observed between high-intensity and low-intensity treatment in subgroups in either study.These resu

27、lts provide definitive evidence to recommend that escalation of CRRT intensity to beyond conventional doses of 25 ml/kg/h is not beneficial for unselected ICU patients with AKI.Possible relationship between delivered dose of CRRT and survival, with results from the ATN and RENAL trials illustrated.

28、282021/10/23 星期六Dose or intensity of CRRT而关于non-septic AKI 的治疗剂量，RENAL研究得到了一个明确的答案: Randomized Evaluation of Normal versus Augmented Levels (RENAL) study: no beneficial effect of CVVHDF at 40 ml/kg/h compared with 25 ml/kg/h.Therefore, current consensus suggests a hemofiltration dose of 25 ml/kg/h i

29、n non-septic AKI with no additional benefit from a dose increase.N Engl J Med 2009, 361:1627-1638.292021/10/23 星期六Dose or intensity of CRRT然而， 需要强调的是：专家的意见是患者治疗剂量要足够，至少25 ml/kg/h。但实际中由于存在可预测的（bags change, nursing.）和不可预测的（surgery, clotting.）治疗中断，意味着剂量要在30-35 ml/kg/h；Septic AKI患者的治疗剂量目前仍存在争议，一些小的前瞻随机研

30、究表明高剂量的血液滤过是有益的。多中心的 “IVOIRE study” (hIgh Volume in Intensive care)，在sepsis引起的AKI，休克和多脏衰患者中，比较35 ml/kg/h vs. 70 ml/kg/h ，不久后，可能会对治疗剂量的争论有所定论。Joannes-Boyau O, Honore PM: Hemofiltration Study: IVOIRE Study: ID NCT00241228., last Accessed in June 2011.Crit Care 2009, 13:R57.J Nephrol

31、 2011, 24:165-176.302021/10/23 星期六Dose or intensity of CRRT“IVOIRE study” (hIgh Volume in Intensive care)初步结果：Although patients included were more severely ill, overall mortality in the IVOIRE study remains very low (39% at 28 days and 52% at 90 days) compared with the RENAL study. This may be due t

32、o the earlier start of treatment at the renal injury level.Awaiting results from this important trial, 35 ml/kg/h should remain the standard dose in septic AKI, particularly in the presence of shock.Joannes-Boyau O, Honore PM: Hemofiltration Study: IVOIRE Study: ID NCT00241228., l

33、ast Accessed in June 2011.312021/10/23 星期六ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions56322021/10/23 星期六RRT in ICU: PreferenceDecision about which technique to use depends on:1. What we want to remove from the plasma 332021/10/23 星期六RRT in ICU: Preference 2. The pati

34、ents cardiovascular statusCRRT causes less rapid fluid shifts and is the preferred option if there is any degree of cardiovascular instability.3. The availability of resourcesCRRT is more labour intensive and more expensive than IHDAvailability of equipment may dictate the form of RRT342021/10/23 星期

35、六RRT in ICU: Preference 4. The clinicians experienceIt is wise to use a form of RRT that is familiar to all the staff involved5. Other specific clinical considerationsConvective modes of RRT may be beneficial if the patient has septic shockCRRT can aid feeding regimes by improving fluid managementCR

36、RT may be associated with better cerebral perfusion in patients with an acute brain injury or fulminant hepatic failure352021/10/23 星期六许多问题悬而未决362021/10/23 星期六标准与个体化You are unique!Standard!372021/10/23 星期六Key PointsIt is recommended to define ARF according to the RIFLE classification system into ARFrisk, ARFinjury and ARFfailure.It is recommended to base the decision when to start RRT not only on the severity of ARF, but also on the severity of other organ failure. Initiation of RRT is to be considered in oliguric patients (RIFLErisk-oliguria or RIFLEinjury-oliguria),