急性肾损伤诊疗指南解读教材课件

急性肾损伤诊疗指南解读急性肾损伤诊疗指南解读1（优选）急性肾损伤诊疗指南解读版（优选）急性肾损伤诊疗指南解读版2AboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryAboutAKIguidelineADQI：2002,3AKI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%AKI流行病学现状患病率：1%（社区）~7.1%（医院）4指南推荐强度指南推荐强度5指南推荐强度指南推荐强度6Guideline1：AKI的定义与分期符合以下情况之一者即可被诊断为AKI：①

48小时内Scr升高超过26.5μmol/L(0.3

mg/dl)；②

Scr

升高超过基线1.5倍—确认或推测7天内发生；③

尿量＜0.5

ml/（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Guideline1：AKI的定义与分期符合以下情况之一者7InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.采用KDIGO推荐的定义和分期标准Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.监测乳酸和碱剩余水平controlonall-causemortality.AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.discontinuationofRRTinAKIisnotevident.Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.NACforpreventionofpostsurgicalAKI.5倍—确认或推测7天内发生；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)慎用高分子量羟乙基淀粉1mg/kg/min,forthepreventionortreatmentofAKI.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.1详细的病史采集和体格检查有助于AKI病因的判断(1A)GFR<60ml/min/1.2评估容量状态后适当补液(1B)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)InitiateRRTemergentlywhenl8RIFLE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-R212RIFLE分级2002年急性透析质量倡议组(ADQI)制定9ConceptualmodelforAKIConceptualmodelforAKI10Guideline2：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)Guideline2：临床评估2.1详细的病史采集和体格11Chapter2.2:RiskassessmentChapter2.2:Riskassessment12Chapter2.2:RiskassessmentChapter2.2:Riskassessment13AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.3mg/dl(X26.5lmol/l)within48hours;

·or

KIncreaseinSCrtoX1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;

·orKUrinevolumeo0.5ml/kg/hfor6hours.

TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)

Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)

EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)

DefinitionandstagingofAKIAKIisdefinedasanyofthe14OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.OverviewofAKI,CKD,andAKD.15AKD

acutekidneydiseasesanddisorder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AKD

acutekidneydiseasesand16AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3个月>3个月AKDAKI3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<3个月NKD无异常AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌17Guideline3：PreventionandTreatmentofAKI3.1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)HIGHRISKGuideline3：PreventionandTre183.3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

3.3造影剂肾病3.4继发于横纹肌溶解的AKI对具CI-AK19Guideline4：AKI的治疗一般治疗(1A)Guideline4：AKI的治疗一般治疗(1A)20Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIStage-basedmanagementofAKIC21GFR<60ml/min/1.Werecommendnotusinglow-dosedopaminetopreventortreatAKI.discontinuationofRRTinAKIisnotevident.controlonneedforRRT.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMeta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CritCare2004;8:R204-R2125g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.BMJ2006;333(7565):420-4255

ml/（kg·h），且持续6小时以上。Thiswillusuallyrequireahigherprescriptionofeffluentvolume.2评估容量状态后适当补液(1B)Effectoffurosemidevs.监测乳酸和碱剩余水平MehtaRL,PascualMT,SorokoSetal.arenalreferral？FriedrichJO,AdhikariN,HerridgeMS.discontinuationofRRTinAKIisnotevident.根据患者病情和RRT模式制定抗凝治疗方案(1C)(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(ANP)toprevent(2C)ortreat(2B)AKI补液治疗Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)GFR<60ml/min/1.补液治疗Intheabse22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

补液治疗：23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）需要调整药物剂量药物治疗(1B)多脏器功能衰竭24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againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425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AKI25Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)Chapter3.4:Theuseofdiuret26Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr27Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr28AnnInternMed2005;142:510-5242评估容量状态后适当补液(1B)医院获得AKI死亡率：10~80%导管仅限于RRT治疗时使用(1D)以预防感染(NotGraded)7天内血肌酐升高50%Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.急性肾损伤诊疗指南解读危重病人伴有AKI时CRRT与IHD的利弊WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.abeneficialroleforloopdiureticsinfacilitating根据患者病情和RRT模式制定抗凝治疗方案(1C)05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；MehtaRL,PascualMT,SorokoSetal.肾脏科与ICU医生协作肾脏科与ICU医生协作Werecommendnotusingoralori.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.ADQI：2002,RIFLETheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI.abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident.AnnInternMed2005;142:510-29甘露醇mannitolisnotscientificallyjustifiedinthepreventionofAKI.甘露醇mannitolisnotscientifica30Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWerecommendnotusinglow-dosedopaminetopreventortreatAKI.（1A）Wesuggestnotusingfenoldopam（非诺多巴）topreventortreatAKI.(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKIVasodilatortherapy:dopamine,31Effectoflow-dosedopamineonmortality.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；Effectoflow-dosedopamineon32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；多巴胺---不建议FriedrichJO,Adhikar33GlycemiccontrolandnutritionalsupportIncriticallyillpatients,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）Glycemiccontrolandnutrition342，或者进行每日透析(1B)由经验丰富的医生负责置管(1A)2002年急性透析质量倡议组(ADQI)制定了ARF的RIFLE分级诊断标准。Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Guideline2：临床评估采用KDIGO推荐的定义和分期标准AnnInternMed2005;142:510–524withpermissionfromAmericanCollegeofPhysicians212；AboutAKIguidelineGFR<60ml/min/1.(NotGraded)discontinuationofRRTinAKIisnotevident.保护非优势侧的上肢血管(2C)肾脏科与ICU医生协作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-AKIWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.难以纠正的容量负荷过重0g/kg/dofproteininnoncatabolicAKIpatientswithoutneedfordialysis(2D),1.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.GrowthfactorinterventionWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.（1B）humanIGF-1：重组人胰岛素样生长因子12，或者进行每日透析(1B)Growthfactorin35Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestnotusingaminoglycosidesforthetreat-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-36Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB.(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.(1A)Preventionofaminoglycoside-37OthermethodsofpreventionofAKI

inthecriticallyillWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT.(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.(2D)Werecommendnotusingoralori.v.NACforpreventionofpostsurgicalAKI.(1A)CI-AKI:预防对比剂急性肾损害Othermethodsofpreventionof38Guideline5：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？Guideline5：医疗资源合理分配多学科参与AKI指39Guideline6：RRT模式的选择建议个体化治疗！(1B)Kanagasundaram,2007Guideline6：RRT模式的选择建议个体化治疗！(40Guideline7：

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Guideline7：

透析器和透析液的选择透析器：透析液41Guideline8：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：血管通路临时建立静脉-静脉通路(142Guideline8：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Guideline8：血管通路保护非优势侧的上肢血管(243Guideline9：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)Guideline9：体外抗凝根据患者病情和RRT模式制44难以纠正的电解质紊乱:低钠血症、高钠血症或高钙血症Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.5

ml/（kg·h），且持续6小时以上。慎用高分子量羟乙基淀粉Werecommendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours.GlycemiccontrolandnutritionalsupportWesuggestnotusingaminoglycosidesforthetreat-mentofinfectionsunlessnosuitable,lessnephro-toxic,therapeuticalternativesareavailable.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;(NotGraded)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.Guideline2：临床评估(NotGraded)ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Werecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.>3周：建议用皮下隧道导管ADQI：2002,RIFLEAKIguidelineforAKI:201105mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；AKIguidline—KDIGO2012Guideline10：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(1B)难以纠正的电解质紊乱:低钠血症、高钠血症或高钙血症Guide45CRRT剂量Werecommenddeliveringaneffluentvolumeof20–25ml/kg/hforCRRTinAKI(1A).Thiswillusuallyrequireahigherprescriptionofeffluentvolume.(NotGraded)CRRT剂量Werecommenddelivering46急性肾损伤诊疗指南解读教材课件47顽固性高钾血症>6.5mmol/L血尿素氮>27mmol/L难以纠正的代谢性酸中毒PH<7.15难以纠正的电解质紊乱:低钠血症、高钠血症或高钙血症肿瘤溶解综合症伴有的高尿酸血症和高磷酸盐血症尿素循环障碍和有机酸尿症导致的高氨血症和甲基丙二酸血症尿量<0.3ml/kg/h持续24h或者无尿12hAKI伴有多器官功能衰竭难以纠正的容量负荷过重累及终末器官：心包炎，脑病，神经病变，肌病和尿毒症出血需要输注血制品和静脉营养重度中毒或药物过量严重的低体温或高体温临床适应症生化指标适应症RRT开始指征(1B)InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.(NotGraded)顽固性高钾血症>6.5mmol/L血尿素氮>27mmol/L48早期应用RRT治疗？“早”：定义不统一BUN<21.5mmol/L（创伤后），或者尿量<100ml/8小时（心脏手术后）达到下列指标12小时内进行RRT：尿量<30/h持续6小时Ccr<20ml/minBUN>27mmol/L开始RRT，死亡风险翻倍早期应用RRT治疗？“早”：定义不统一49DefinitionandstagingofAKIGuideline2：临床评估Effectoffurosemidevs.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CI-AKI:预防对比剂急性肾损害(NotGraded)CRRT与IHD相比具备以下优点：abeneficialroleforloopdiureticsinfacilitatingWesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)密切监测CVP和尿量9%氯化钠和碳酸氢钠扩容(1B)KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMehtaRL,PascualMT,SorokoSetal.慎用高分子量羟乙基淀粉discontinuationofRRTinAKIisnotevident.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.难以纠正的容量负荷过重2评估容量状态后适当补液(1B)1mg/kg/min,forthepreventionortreatmentofAKI.(NotGraded)BMJ2006;333(7565):420-425危重病人伴有AKI时CRRT与IHD的利弊CRRT与IHD相比具备以下优点：①稳定的血流动力学，缓慢、连续性清除液体和溶质，②溶质清除率高;③持续稳定地控制氮质血症及电解质和水盐代谢;④清除炎症介质，能够不断清除循环中存在的毒素和中小分子物质;⑤改善营养支持，保障营养补充及药物治疗,维持内环境稳定。缺点：花费大，机器昂贵，需要专业的医护团队，治疗期间不能外出治疗、检查等。DefinitionandstagingofAKI危50急性肾损伤诊疗指南解读急性肾损伤诊疗指南解读51（优选）急性肾损伤诊疗指南解读版（优选）急性肾损伤诊疗指南解读版52AboutAKIguidelineADQI：2002,RIFLEAKIN：2005,modifieddefinitionandstagingsystemKDIGO:2011,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:2011AKIguidline—KDIGO2012KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryAboutAKIguidelineADQI：2002,53AKI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%AKI流行病学现状患病率：1%（社区）~7.1%（医院）54指南推荐强度指南推荐强度55指南推荐强度指南推荐强度56Guideline1：AKI的定义与分期符合以下情况之一者即可被诊断为AKI：①

48小时内Scr升高超过26.5μmol/L(0.3

mg/dl)；②

Scr

升高超过基线1.5倍—确认或推测7天内发生；③

尿量＜0.5

ml/（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Guideline1：AKI的定义与分期符合以下情况之一者57InitiateRRTemergentlywhenlife-threateningchangesinfluid,electrolyte,andacid-basebalanceexist.RESEARCHRECOMMENDATION：WerecommendfurthertrialsofANPatdosesbelow0.Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.采用KDIGO推荐的定义和分期标准Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.监测乳酸和碱剩余水平controlonall-causemortality.AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.discontinuationofRRTinAKIisnotevident.Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.NACforpreventionofpostsurgicalAKI.5倍—确认或推测7天内发生；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)慎用高分子量羟乙基淀粉1mg/kg/min,forthepreventionortreatmentofAKI.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.1详细的病史采集和体格检查有助于AKI病因的判断(1A)GFR<60ml/min/1.2评估容量状态后适当补液(1B)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)InitiateRRTemergentlywhenl58RIFLE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-R212RIFLE分级2002年急性透析质量倡议组(ADQI)制定59ConceptualmodelforAKIConceptualmodelforAKI60Guideline2：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)Guideline2：临床评估2.1详细的病史采集和体格61Chapter2.2:RiskassessmentChapter2.2:Riskassessment62Chapter2.2:RiskassessmentChapter2.2:Riskassessment63AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.3mg/dl(X26.5lmol/l)within48hours;

·or

KIncreaseinSCrtoX1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;

·orKUrinevolumeo0.5ml/kg/hfor6hours.

TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)

Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)

EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)

DefinitionandstagingofAKIAKIisdefinedasanyofthe64OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.OverviewofAKI,CKD,andAKD.65AKD

acutekidneydiseasesanddisorder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AKD

acutekidneydiseasesand66AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3个月>3个月AKDAKI3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<3个月NKD无异常AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌67Guideline3：PreventionandTreatmentofAKI3.1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)HIGHRISKGuideline3：PreventionandTre683.3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

3.3造影剂肾病3.4继发于横纹肌溶解的AKI对具CI-AK69Guideline4：AKI的治疗一般治疗(1A)Guideline4：AKI的治疗一般治疗(1A)70Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIStage-basedmanagementofAKIC71GFR<60ml/min/1.Werecommendnotusinglow-dosedopaminetopreventortreatAKI.discontinuationofRRTinAKIisnotevident.controlonneedforRRT.KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryMeta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.CritCare2004;8:R204-R2125g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.BMJ2006;333(7565):420-4255

ml/（kg·h），且持续6小时以上。Thiswillusuallyrequireahigherprescriptionofeffluentvolume.2评估容量状态后适当补液(1B)Effectoffurosemidevs.监测乳酸和碱剩余水平MehtaRL,PascualMT,SorokoSetal.arenalreferral？FriedrichJO,AdhikariN,HerridgeMS.discontinuationofRRTinAKIisnotevident.根据患者病情和RRT模式制定抗凝治疗方案(1C)(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(ANP)toprevent(2C)ortreat(2B)AKI补液治疗Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)GFR<60ml/min/1.补液治疗Intheabse72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

补液治疗：73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）需要调整药物剂量药物治疗(1B)多脏器功能衰竭74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againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425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AKI75Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)Chapter3.4:Theuseofdiuret76Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr77Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;Effectoffurosemidevs.contr78AnnInternMed2005;142:510-5242评估容量状态后适当补液(1B)医院获得AKI死亡率：10~80%导管仅限于RRT治疗时使用(1D)以预防感染(NotGraded)7天内血肌酐升高50%Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.急性肾损伤诊疗指南解读危重病人伴有AKI时CRRT与IHD的利弊WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.abeneficialroleforloopdiureticsinfacilitating根据患者病情和RRT模式制定抗凝治疗方案(1C)05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie；MehtaRL,PascualMT,SorokoSetal.肾脏科与ICU医生协作肾脏科与ICU医生协作Werecommendnotusingoralori.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.ADQI：2002,RIFLETheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestth