ICU中的血液净化指南之我见课件

ICU中的血液净化指南之我见ICU中的血液净化指南之我见ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofIntroductionMethodsofextracorporealrenalreplacementtherapy(RRT)havebeenusedforthesupportivetreatmentofAKIforover60years.CRRTforthecriticallyillpatientwithARFwasintroducedin1977byKrameretal.Sincethen,manystudieshavereportedonCRRTinthecriticallyill.KlinWochenschr1977;55:1121-1122.IntroductionMethodsofextracoIntroductionButforseveralreasonscomparisonamongstudiesisdifficult:Varioustreatmentmodalitieshavebeenappliedinheterogeneouspopulations.DifferencesinclinicalsettingandunderlyingmolecularbiologicalmechanismsthatinitiateandmaintainARF.Furthermore,morethan35definitionsofARF.Practicepatternsvarywidelybetweenindividualcenters.Uptonow,therearenostandardguidelinesfortheapplicationofCRRTincriticallyillpatients.CurrOpinCritCare2002;8:509-514.IntroductionButforseveralreIntroductionTheRIFLEClassificationforacuterenalfailureCritCare2004;8:R204-R212.IntroductionTheRIFLEClassifiIntroductionConclusions:Morethen200differentdefinitionsofARFandabout90RRTstartcriteriawerereported.OliguriaandRIFLEwerethemostfrequentcriteriausedtodefineARF.RIFLEcriteriamightshowaclinicalimpactonfuturedailypracticeandresearch.DifferentRRTtechniquesareavailableinmostcenters,butagenerallackoftreatmentdosestandardizationisnotedbyoursurvey.Non-renalindicationstoRRTstillneedtofindadefinitiveroleinroutinepractice.NephrolDialTransplant(2006)21:690–696IntroductionConclusions:NephroInthepast,theinteractionbetweennephrologyandintensivecarewasminimal.Today,thereiscontinuousinteractionwithseveralmomentsofhighinteractionduetocommonpatientsandcomplexsyndromes,andmuchofthetreatmentofAKIhasmovedfromtherenalwardintoICUs.IntroductionContribNephrol.Basel,Karger,2010(166):1–3Inthepast,theinteractionbContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseorintensityofCRRT4Conclusions56ContentsIntroduction1TypeofTypeoftherapyClassificationofbloodpurificationincriticalcare(BPCC)technologyPMX=polymyxin-Bimmobilizedfiber;PMMA=polymethylmethacrylate;PAN=polyacrylonitrile;PEPA=polyetherpolymeralloyContribNephrol.Basel,Karger,2010(166):11–20TypeoftherapyClassificationTypeoftherapyAsacontinuoustherapy,CRRTcanberapidlytailoredtochangesinapatient’sclinicalconditionduringcriticalillnessBloodpurificationincriticalcareContribNephrol.Basel,Karger,2010(166):11–20HDF=hemodiafiltrationTypeoftherapyAsacontinuousTypeoftherapyTheseadvantageshavecontributedtothewidespreaduptakeofCRRTasthefirst-choiceRRTinICUsthroughoutAustralia,JapanandEurope.Intheseregions,CRRTisusuallyinitiatedandmanagedwithintheICU,withRRTbeingintegratedwithotheraspectsofthemanagementofcriticalillnessNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyTheseadvantageTypeoftherapyInnorthAmerica,however,traditionalstructuresofICUmanagementfavoran‘open-ICU’approach:Withinthismodel,RRTisusuallyprescribedbyanephrologistintheICUandisinitiatedbyadialysisnurseInthisenvironment,IHDhastheadvantageofrequiringonlydailyoralternate-dayattendancebytherenalteamConversely,therelativelaborcostsofprovidingCRRTareincreased,aneffectthatiscompoundedbythelargerfixedcostsandhigherconsumablerequirementsofCRRTTheselogisticfactorshaveledtoapreferenceforIHDoverCRRTbeingmaintainedinICUsthatusethenorthAmerican.Nat.Rev.Nephrol.2010:6:521–529.TypeoftherapyInnorthAmericTypeoftherapyClinicalstudiesofCRRTintheICUThediversityofclinicalapproachestothetreatmentofAKIintheICUisillustratedbytheresultsoftheBESTKidneystudy,ThemultinationalepidemiologicalstudyofRRTpracticeintheICUStudydocumentedthetreatmentofAKIin1,738patientsin54ICUsonfivecontinentsNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyClinicalstudieTypeoftherapyBESTstudyresultsCRRTwasthemostcommonchoiceofinitialRRTtreatment,with80%ofpatientsonCRRT;IHDusewasmostlyrestrictedtoICUsinnorthandsouthAmerica,whereitwasusedasinitialtherapyin30–40%ofpatients,while,bycontrast,CRRTisusedfirstin100%ofICUsinAustralia.AmongpatientsreceivingCRRT,however,markedvariationinthemodality,intensity,timingwasobservedMakingitdifficulttocompareoutcomesbetweenpatientsonCRRTandthoseonIHDNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyBESTstudyresuTypeoftherapyNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyNat.Rev.Nephr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IHDTypeoftherapyKidneyInt2009,76:422-427.BMCNephrol2010,11:32.NephrolDialTransplant2009,24:512-518.Lancet2006,368:379-385.

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。CritCareMed2008,36:610-617.KidneyInt2009,76:422-427.NatRevNephrol2010,9:521-529.ClinPharmacolTher2009,86:562-565.目前共识：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ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofTimingofCRRTTherighttimetostartRRTisstillatopicofdebate.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CritCare2009,13:211.TimingofCRRTTherighttimetTimingofCRRTThereissignificantvariationinthetimingofinitiationofRRT,withuptotwo-folddifferencesinthereportedvaluesofBUN,creatinine,orurineoutputatRRTinitiation.ClinicalstudiesevaluatingthetimingofinitiationofCRRTincriticallyillpatientsTimingofCRRTThereissignifiTimingofCRRTIntheabove-mentionedstudiesthereisacleartrendtowardabetteroutcomewithearliertimingofRRT.IntheabsenceoflargeRCTscomparingearlytolateinitiationofRRT,nofirmoverallrecommendationsfortimingofRRTcanbemade.TimingofCRRTIntheabove-menTimingofCRRT目前广为接受的SepticAKI开始RRT时机，尤其是在septicshock时：RIFLEinjurystage(orAKINstage2)butconsensusonthistopicawaitsresultsfromlarge-scaleRCTs.TimingofCRRT目前广为接受的SepticAKTimingofCRRT除AKI外，患者的一些其他情况也需要行早期RRT治疗：mainlypediatric,treatedbyECMOforsevereARDS.Fluidoverloaddefinitelyplaysaroleintiming,becauseCRRTprovedsuccessfulinpatientswithoutAKIbutrefractorytodiuretics.治疗时机的标准在不断发展，包括：severityoforgandysfunction(SOFAscore)；severityofAKI(RIFLEorAKINstage)；fluidoverloadstatus；

timefromadmission；biomarkeruse,etc.但他们在日常临床实践中的应用价值仍然需要评估KidneyInt2010,77:469-470.KidneyInt2009,76:1289-1292JAmSocNephrol2011,22:810-820.TimingofCRRT除AKI外，患者的一些其他情况也TimingofCRRTWheninitiationofRRTisconsidered,itisimportanttorealizethat:theconsequencesofureamictoxicity,metabolicacidosisand/orfluidoverloadarelikelytobemoresevereinthecriticallyillpatient.Moreover,renalfunctionisunlikelytorecoverwithinashortperiodduringpersistentandseverefailureofotherorgans.Furthermore,variousinflammatorymediatorsareclearedbythekidney.TimingofCRRTWheninitiationTimingofCRRT最近的一项前瞻性研究和两项meta-analysis明确地支持earlytimingThefindingsofthesestudiessupportearlierinitiationofacuteRRTIntheabsenceofnewevidencefromsuitably-designedrandomisedtrials,adefinitivetreatmentrecommendationcannotbemadeTimingofCRRT最近的一项前瞻性研究和两项metContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofDoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTBoththeATNandRENALstudiesfailedtodetectanysurvivalbenefitfrommore-intensiveRRTAndnosignificantdifferencesinmortalityrateswereobservedbetweenhigh-intensityandlow-intensitytreatmentinsubgroupsineitherstudy.TheseresultsprovidedefinitiveevidencetorecommendthatescalationofCRRTintensitytobeyondconventionaldosesof25ml/kg/hisnotbeneficialforunselectedICUpatientswithAKI.PossiblerelationshipbetweendelivereddoseofCRRTandsurvival,withresultsfromtheATNandRENALtrialsillustrated.DoseorintensityofCRRTBothDoseorintensityofCRRT而关于non-septicAKI的治疗剂量，RENAL研究得到了一个明确的答案:RandomizedEvaluationofNormalversusAugmentedLevels(RENAL)study:nobeneficialeffectofCVVHDFat40ml/kg/hcomparedwith25ml/kg/h.Therefore,currentconsensussuggestsahemofiltrationdoseof25ml/kg/hinnon-septicAKIwithnoadditionalbenefitfromadoseincrease.NEnglJMed2009,361:1627-1638.DoseorintensityofCRRT而关于noDoseorintensityofCRRT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25ml/kg/h。但实际中由于存在可预测的（bagschange,nursing...）和不可预测的（surgery,clotting...）治疗中断，意味着剂量要在30-35ml/kg/h；SepticAKI患者的治疗剂量目前仍存在争议，一些小的前瞻随机研究表明高剂量的血液滤过是有益的。多中心的“IVOIREstudy”(hIghVolumeinIntensivecare)，在sepsis引起的AKI，休克和多脏衰患者中，比较35ml/kg/h

vs.70ml/kg/h

，不久后，可能会对治疗剂量的争论有所定论。Joannes-BoyauO,HonorePM:HemofiltrationStudy:IVOIREStudy:IDNCT00241228.,lastAccessedinJune2011.CritCare2009,13:R57.JNephrol2011,24:165-176.DoseorintensityofCRRT然而，需DoseorintensityofCRRT“IVOIREstudy”(hIghVolumeinIntensivecare)初步结果：Althoughpatientsincludedweremoreseverelyill,overallmortalityintheIVOIREstudyremainsverylow(39%at28daysand52%at90days)comparedwiththeRENALstudy.Thismaybeduetotheearlierstartoftreatmentattherenalinjurylevel.Awaitingresultsfromthisimportanttrial,35ml/kg/hshouldremainthestandarddoseinsepticAKI,particularlyinthepresenceofshock.Joannes-BoyauO,HonorePM:HemofiltrationStudy:IVOIREStudy:IDNCT00241228.,lastAccessedinJune2011.DoseorintensityofCRRT“IVOIContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofRRTinICU:PreferenceDecisionaboutwhichtechniquetousedependson:1.WhatwewanttoremovefromtheplasmaRRTinICU:PreferenceDecisionRRTinICU:Preference2.Thepatient`scardiovascularstatusCRRTcauseslessrapidfluidshiftsandisthepreferredoptionifthereisanydegreeofcardiovascularinstability.3.TheavailabilityofresourcesCRRTismorelabourintensiveandmoreexpensivethanIHDAvailabilityofequipmentmaydictatetheformofRRTRRTinICU:Preference2.TheRRTinICU:Preference4.Theclinician`sexperienceItiswisetouseaformofRRTthatisfamiliartoallthestaffinvolved5.

OtherspecificclinicalconsiderationsConvectivemodesofRRTmaybebeneficialifthepatienthassepticshockCRRTcanaidfeedingregimesbyimprovingfluidmanagementCRRTmaybeassociatedwithbettercerebralperfusioninpatientswithanacutebraininjuryorfulminanthepaticfailureRRTinICU:Preference4.The许多问题悬而未决许多问题悬而未决标准与个体化Youareunique!Standard!标准与个体化Youareunique!Standard!KeyPointsItisrecommendedtodefineARFaccordingtotheRIFLEclassificationsystemintoARFrisk,ARFinjuryandARFfailure.ItisrecommendedtobasethedecisionwhentostartRRTnotonlyontheseverityofARF,butalsoontheseverityofotherorganfailure.InitiationofRRTistobeconsideredinoliguricpatients(RIFLErisk-oliguriaorRIFLEinjury-oliguria),despiteadequatefluidresuscitation,and/orapersistingsteepriseinserumcreatinine.KeyPointsItisrecommendedtoKeyPointsRRTmaybepostponedwhentheunderlyingdiseaseisimproving,otherorganfailurerecoveringandtheslopeintheserumcreatininerisedeclines,inordertoseeifrenalfunctionisalsorecovering.ItisrecommendedtocontinueRRTaslongasthecriteriadefiningsevereoliguricARF(RIFLEfailure-oliguria)arepresent.Iftheclinicalconditionimproves,itmaybeconsideredtowaitbeforeconnectinganewcircuittoseewhetherrenalfunctionrecovers.RRTshouldberestartedincaseofclinicalormetabolicdeterioration.KeyPointsRRTmaybepostponedKeyPointsTherecommendeddelivered(notprescribed)ultrafiltrate(dialysate)flowduringCVVH(D)is35mL/kg/hinpostdilution.AhigherdoseappliedforashortperiodmaybeconsideredinSepsis/SIRS.Thedoseneedstobeadjustedforpredilution.Innon-shockpatients,continuousandintermittenttreatmentsareequivalentregardingsurvival.However,CRRTisrecommendedoverIHDforpatientswithARFwhohave,orareatriskfor,cerebraloedema.CRRTispreferredinthemanagementofpatientswithARFandshock.KeyPointsTherecommendeddeliThankYou!ThankYou!ICU中的血液净化指南之我见ICU中的血液净化指南之我见ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofIntroductionMethodsofextracorporealrenalreplacementtherapy(RRT)havebeenusedforthesupportivetreatmentofAKIforover60years.CRRTforthecriticallyillpatientwithARFwasintroducedin1977byKrameretal.Sincethen,manystudieshavereportedonCRRTinthecriticallyill.KlinWochenschr1977;55:1121-1122.IntroductionMethodsofextracoIntroductionButforseveralreasonscomparisonamongstudiesisdifficult:Varioustreatmentmodalitieshavebeenappliedinheterogeneouspopulations.DifferencesinclinicalsettingandunderlyingmolecularbiologicalmechanismsthatinitiateandmaintainARF.Furthermore,morethan35definitionsofARF.Practicepatternsvarywidelybetweenindividualcenters.Uptonow,therearenostandardguidelinesfortheapplicationofCRRTincriticallyillpatients.CurrOpinCritCare2002;8:509-514.IntroductionButforseveralreIntroductionTheRIFLEClassificationforacuterenalfailureCritCare2004;8:R204-R212.IntroductionTheRIFLEClassifiIntroductionConclusions:Morethen200differentdefinitionsofARFandabout90RRTstartcriteriawerereported.OliguriaandRIFLEwerethemostfrequentcriteriausedtodefineARF.RIFLEcriteriamightshowaclinicalimpactonfuturedailypracticeandresearch.DifferentRRTtechniquesareavailableinmostcenters,butagenerallackoftreatmentdosestandardizationisnotedbyoursurvey.Non-renalindicationstoRRTstillneedtofindadefinitiveroleinroutinepractice.NephrolDialTransplant(2006)21:690–696IntroductionConclusions:NephroInthepast,theinteractionbetweennephrologyandintensivecarewasminimal.Today,thereiscontinuousinteractionwithseveralmomentsofhighinteractionduetocommonpatientsandcomplexsyndromes,andmuchofthetreatmentofAKIhasmovedfromtherenalwardintoICUs.IntroductionContribNephrol.Basel,Karger,2010(166):1–3Inthepast,theinteractionbContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseorintensityofCRRT4Conclusions56ContentsIntroduction1TypeofTypeoftherapyClassificationofbloodpurificationincriticalcare(BPCC)technologyPMX=polymyxin-Bimmobilizedfiber;PMMA=polymethylmethacrylate;PAN=polyacrylonitrile;PEPA=polyetherpolymeralloyContribNephrol.Basel,Karger,2010(166):11–20TypeoftherapyClassificationTypeoftherapyAsacontinuoustherapy,CRRTcanberapidlytailoredtochangesinapatient’sclinicalconditionduringcriticalillnessBloodpurificationincriticalcareContribNephrol.Basel,Karger,2010(166):11–20HDF=hemodiafiltrationTypeoftherapyAsacontinuousTypeoftherapyTheseadvantageshavecontributedtothewidespreaduptakeofCRRTasthefirst-choiceRRTinICUsthroughoutAustralia,JapanandEurope.Intheseregions,CRRTisusuallyinitiatedandmanagedwithintheICU,withRRTbeingintegratedwithotheraspectsofthemanagementofcriticalillnessNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyTheseadvantageTypeoftherapyInnorthAmerica,however,traditionalstructuresofICUmanagementfavoran‘open-ICU’approach:Withinthismodel,RRTisusuallyprescribedbyanephrologistintheICUandisinitiatedbyadialysisnurseInthisenvironment,IHDhastheadvantageofrequiringonlydailyoralternate-dayattendancebytherenalteamConversely,therelativelaborcostsofprovidingCRRTareincreased,aneffectthatiscompoundedbythelargerfixedcostsandhigherconsumablerequirementsofCRRTTheselogisticfactorshaveledtoapreferenceforIHDoverCRRTbeingmaintainedinICUsthatusethenorthAmerican.Nat.Rev.Nephrol.2010:6:521–529.TypeoftherapyInnorthAmericTypeoftherapyClinicalstudiesofCRRTintheICUThediversityofclinicalapproachestothetreatmentofAKIintheICUisillustratedbytheresultsoftheBESTKidneystudy,ThemultinationalepidemiologicalstudyofRRTpracticeintheICUStudydocumentedthetreatmentofAKIin1,738patientsin54ICUsonfivecontinentsNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyClinicalstudieTypeoftherapyBESTstudyresultsCRRTwasthemostcommonchoiceofinitialRRTtreatment,with80%ofpatientsonCRRT;IHDusewasmostlyrestrictedtoICUsinnorthandsouthAmerica,whereitwasusedasinitialtherapyin30–40%ofpatients,while,bycontrast,CRRTisusedfirstin100%ofICUsinAustralia.AmongpatientsreceivingCRRT,however,markedvariationinthemodality,intensity,timingwasobservedMakingitdifficulttocompareoutcomesbetweenpatientsonCRRTandthoseonIHDNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyBESTstudyresuTypeoftherapyNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyNat.Rev.Nephr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IHDTypeoftherapyKidneyInt2009,76:422-427.BMCNephrol2010,11:32.NephrolDialTransplant2009,24:512-518.Lancet2006,368:379-385.

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。CritCareMed2008,36:610-617.KidneyInt2009,76:422-427.NatRevNephrol2010,9:521-529.ClinPharmacolTher2009,86:562-565.目前共识：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ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofTimingofCRRTTherighttimetostartRRTisstillatopicofdebate.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CritCare2009,13:211.TimingofCRRTTherighttimetTimingofCRRTThereissignificantvariationinthetimingofinitiationofRRT,withuptotwo-folddifferencesinthereportedvaluesofBUN,creatinine,orurineoutputatRRTinitiation.ClinicalstudiesevaluatingthetimingofinitiationofCRRTincriticallyillpatientsTimingofCRRTThereissignifiTimingofCRRTIntheabove-mentionedstudiesthereisacleartrendtowardabetteroutcomewithearliertimingofRRT.IntheabsenceoflargeRCTscomparingearlytolateinitiationofRRT,nofirmoverallrecommendationsfortimingofRRTcanbemade.TimingofCRRTIntheabove-menTimingofCRRT目前广为接受的SepticAKI开始RRT时机，尤其是在septicshock时：RIFLEinjurystage(orAKINstage2)butconsensusonthistopicawaitsresultsfromlarge-scaleRCTs.TimingofCRRT目前广为接受的SepticAKTimingofCRRT除AKI外，患者的一些其他情况也需要行早期RRT治疗：mainlypediatric,treatedbyECMOforsevereARDS.Fluidoverloaddefinitelyplaysaroleintiming,becauseCRRTprovedsuccessfulinpatientswithoutAKIbutrefractorytodiuretics.治疗时机的标准在不断发展，包括：severityoforgandysfunction(SOFAscore)；severityofAKI(RIFLEorAKINstage)；fluidoverloadstatus；

timefromadmission；biomarkeruse,etc.但他们在日常临床实践中的应用价值仍然需要评估KidneyInt2010,77:469-470.KidneyInt2009,76:1289-1292JAmSocNephrol2011,22:810-820.TimingofCRRT除AKI外，患者的一些其他情况也TimingofCRRTWheninitiationofRRTisconsidered,itisimportanttorealizethat:theconsequencesofureamictoxicity,metabolicacidosisand/orfluidoverloadarelikelytobemoresevereinthecriticallyillpatient.Moreover,renalfunctionisunlikelytorecoverwithinashortperiodduringpersistentandseverefailureofotherorgans.Furthermore,variousinflammatorymediatorsareclearedbythekidney.TimingofCRRTWheninitiationTimingofCRRT最近的一项前瞻性研究和两项meta-analysis明确地支持earlytimingThefindingsofthesestudiessupportearlierinitiationofacuteRRTIntheabsenceofnewevidencefromsuitably-designedrandomisedtrials,adefinitivetreatmentrecommendationcannotbemadeTimingofCRRT最近的一项前瞻性研究和两项metContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofDoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTDoseorintensityofCRRTBoththeATNandRENALstudiesfailedtodetectanysurvivalbenefitfrommore-intensiveRRTAndnosignificantdifferencesinmortalityrateswereobservedbetweenhigh-intensityandlow-intensitytreatmentinsubgroupsineitherstudy.TheseresultsprovidedefinitiveevidencetorecommendthatescalationofCRRTintensitytobeyondconventionaldosesof25ml/kg/hisnotbeneficialforunselectedICUpatientswithAKI.PossiblerelationshipbetweendelivereddoseofCRRTandsurvival,withresultsfromtheATNandRENALtrialsillustrated.DoseorintensityofCRRTBothDoseorintensityofCRRT而关于non-septicAKI的治疗剂量，RENAL研究得到了一个明确的答案:RandomizedEvaluationofNormalversusAugmentedLevels(RENAL)study:nobeneficialeffectofCVVHDFat40ml/kg/hcomparedwith25ml/kg/h.Therefore,currentconsensussuggestsahemofiltrationdoseof25ml/kg/hinnon-septicAKIwithnoadditionalbenefitfromadoseincrease.NEnglJMed2009,361:1627-1638.DoseorintensityofCRRT而关于noDoseorintensityofCRRT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25ml/kg/h。但实际中由于存在可预测的（bagschange,nursing...）和不可预测的（surgery,clotting...）治疗中断，意味着剂量要在30-35ml/kg/h；SepticAKI患者的治疗剂量目前仍存在争议，一些小的前瞻随机研究表明高剂量的血液滤过是有益的。多中心的“IVOIREstudy”(hIghVolumeinIntensivecare)，在sepsis引起的AKI，休克和多脏衰患者中，比较35ml/kg/h

vs.70ml/kg/h

，不久后，可能会对治疗剂量的争论有所定论。Joannes-BoyauO,HonorePM:HemofiltrationStudy:IVOIREStudy:IDNCT00241228.,lastAccessedinJune2011.CritCare2009,13:R57.JNephrol2011,24:165-176.DoseorintensityofCRRT然而，需DoseorintensityofCRRT“IVOIREstudy”(hIghVolumeinIntensivecare)初步结果：Althoughpatientsincludedweremoreseverelyill,overallmortalityintheIVOIREstudyremainsverylow(39%at28daysand52%at90days)comparedwiththeRENALstudy.Thismaybeduetotheearlierstartoftreatmentattherenalinjurylevel.Awaitingresultsfromthisimportanttrial,35ml/kg/hshouldremainthestandarddoseinsepticAKI,particularlyinthepresenceofshock.Joannes-BoyauO,HonorePM:HemofiltrationStudy:IVOIREStudy:IDNCT00241228.,lastAccessedinJune2011.DoseorintensityofCRRT“IVOIContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56ContentsIntroduction1TypeofRRTinICU:PreferenceDecisionaboutwhichtechniquetousede