ICU中的血液净化指南之我见.ppt

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,ICU,中的血液净化指南之我见,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose of CRRT,4,Conclusions,5,6,Introduction,Methods 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 with 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.,Introduction,But for several reasons comparison among studies is difficult:,Various treatment modalities have been applied in heterogeneous 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 CRRT in critically ill patients.,Curr Opin Crit Care 2002;8:509-514.,Introduction,The RIFLE Classification for acute renal failure,Crit Care 2004;8:R204-R212.,Introduction,Conclusions:,More then 200 different definitions of ARF and about 90 RRT start criteria were reported.Oliguria 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 indications to RRT still need to find a definitive role in routine practice.,Nephrol Dial Transplant(2006)21:690696,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 patients and complex syndromes,and much of the treatment of AKI has moved from the renal ward into ICUs.,Introduction,Contrib Nephrol.Basel,Karger,2010(166):13,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose or intensity of CRRT,4,Conclusions,5,6,Type of therapy,Classification of blood purification in critical care(BPCC)technology,PMX=polymyxin-B immobilized fiber;PMMA=polymethylmethacrylate;,PAN=polyacrylonitrile;PEPA=polyether polymer alloy,Contrib Nephrol.Basel,Karger,2010(166):1120,Type of therapy,As a continuous therapy,CRRT can be rapidly tailored to changes in a patients clinical condition during critical illness,Blood purification in critical care,Contrib Nephrol.Basel,Karger,2010(166):1120,HDF=hemodiafiltration,Type of therapy,These advantages have contributed to the widespread uptake of CRRT as the first-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 illness,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,In north America,however,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 team,Conversely,the relative labor costs of providing CRRT are increased,an effect that is compounded by the larger fixed costs and higher consumable requirements of CRRT,These logistic factors have led to a preference for IHD over CRRT being maintained in ICUs that use the north American.,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,Clinical studies of CRRT in the ICU,The 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 ICU,Study documented the treatment of AKI in 1,738 patients in 54 ICUs on five continents,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,BEST study results,CRRT 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,where 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 observed,Making it difficult to compare outcomes between patients on CRRT and those on IHD,Nat.Rev.Nephrol.2010:6:521529.,Type of therapy,Nat.Rev.Nephrol.2010:6521529.,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,IHD,Type of therapy,Kidney Int 2009,76:422-427.,BMC Nephrol 2010,11:32.,Nephrol Dial Transplant 2009,24:512-518.,Lancet 2006,368:379-385.,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。,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：,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose of CRRT,4,Conclusions,5,6,Timing of CRRT,The 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.,Timing of CRRT,There 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 patients,Timing of CRRT,In 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.,Timing,of CRRT,目前广为接受的,Septic AKI,开始,RRT,时机，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.,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 successful 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 2009,76:1289-1292,J Am Soc Nephrol 2011,22:810-820.,Timing of CRRT,When 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 is unlikely to recover within a short period during persistent and severe failure of other organs.,Furthermore,various inflammatory mediators are cleared by the kidney.,Timing of CRRT,最近的一项前瞻性研究和两项,meta-analysis,明确地支持,early timing,The findings of these studies support,earlier initiation of acute RRT,In the absence of new evidence from suitably-designed randomised trials,a definitive treatment recommendation cannot be made,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose of CRRT,4,Conclusions,5,6,Dose or intensity of CRRT,Dose or intensity of CRRT,Dose or intensity of CRRT,Both 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 results 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.,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 in non-septic AKI with no additional benefit from a dose increase.,N Engl J Med 2009,361:1627-1638.,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:clinicaltrials.,gov ID NCT00241228.,last Accessed in June 2011.,Crit Care 2009,13:R57.,J Nephrol 2011,24:165-176.,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 to 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:clinicaltrials.,gov ID NCT00241228.,last Accessed in June 2011.,Contents,Introduction,1,Type of therapy,2,Timing of CRRT,3,Dose of CRRT,4,Conclusions,5,6,RRT in ICU:Preference,Decision about which technique to use depends on:,1.What we want to remove from the plasma,RRT in ICU:Preference,2.The patients cardiovascular status,CRRT causes less rapid fluid shifts and is the preferred option if there is any degree of cardiovascular instability.,3.The availability of resources,CRRT is more labour intensive and more expensive than IHD,Availability of equipment may dictate the form of RRT,RRT in ICU:Preference,4.The clinicians experience,It is wise to use a form of RRT that is familiar to all the staff involved,5.,Other specific clinical considerations,Convective modes of RRT may be beneficial if the patient has septic shock,CRRT can aid feeding regimes by improving fluid management,CRRT may be associated with better cerebral perfusion in patients with an acute brain injury or fulminant hepatic failure,许多问题悬而未决,标准与个体化,You are unique!,Standard!,Key Points,It is recommended to define ARF according to the RIFLE classification system into ARF,risk,ARF,injury,and ARF,failure,.,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(RIFLE,risk,-oliguria or RIFLE,injury,-oliguria),despite adequate fluid resuscitation,and/or a persisting steep rise in serum creatinine.,Key Points,RRT may be postponed when the underlying disease is improving,other organ failure recovering and the slope in the serum creatinine rise declines,in order to see if renal function is also recovering.,It is recommended to continue RRT as long as the criteria defining severe oliguric ARF(RIFLE,failure,-oliguria)are present.If the clinical condition improves,it may be considered to wait before connecting a new circuit to see whether renal function recovers.RRT should be restarted in case of clinical or metabolic deterioration.,Key Points,The recommended delivered(not prescribed)ultrafiltrate(dialysate)flow during CVVH(D)is 35 mL/kg/h in postdilution.A higher dose applied for a short period may be considered in Sepsis/SIRS.The dose needs to be adjusted for predilution.,In non-shock patients,continuous and intermittent treatments are equivalent regarding survival.However,CRRT is recommended over IHD for patients with ARF who have,or are at risk for,cerebral oedema.CRRT is preferred in the management of patients with ARF and shock.,Thank You!,