急性肾损伤诊疗指南解读KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012KDIGO：Kidney Disease Improving Global Outcomes急性肾损伤急性肾损伤(AKI)与急性肾衰竭与急性肾衰竭(ARF)国际肾脏病和急救医学界将国际肾脏病和急救医学界将ARF 改为急性肾损伤改为急性肾损伤（Acute Kidney Injury, AKI）。）。AKI 覆盖的肾损伤覆盖的肾损伤 WarnockDG.JAmSocNephrol16:3149-3150,2006BiesenWVetal.CJASN.2006GFR正常伴肾脏损伤的标志物改变GFR开始下降GFR明显异常About AKI guidelineADQI：2002, RIFLEAKIN：2005, modified definition and staging systemKDIGO: 2011, First clinical guideline for AKIWaitingforpublishedinthissummerAKI guideline for AKI :2011UKRenalAssociationFinalVersion08.03.11AKI guidlineKDIGO 2012KDIGO Clinical Practice Guideline for Acute Kidney InjuryAKI流行病学现状患病率：1%（社区）7.1%（医院）人群发病率：486630pmp/yAKI需要RRT发病率：22203pmp/y医院获得AKI死亡率：1080%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26.5mol/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/（kgh），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分级分级2002 2002 年急性透析质量倡议组年急性透析质量倡议组(ADQI)(ADQI)制定了制定了ARFARF的的 RIFLE RIFLE 分级诊断标准。分级诊断标准。Bellomo R, et al. Crit Care 2004;8:R204-R212Conceptual model for AKIGuideline2：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)Chapter 2.2: Risk assessmentChapter 2.2: Risk assessment AKI is defined as any of the following (Not Graded ):AKI is defined as any of the following (Not Graded ): AKI is defined as any of the following (Not Graded ):AKI is defined as any of the following (Not Graded ): KIncrease in SCr by X 0.3 mg/dl ( X26.5 lmol/l)within 48 hours;KIncrease in SCr by X 0.3 mg/dl ( X26.5 lmol/l)within 48 hours; oror KIncrease in SCr to X1.5 times baseline, whichis known or KIncrease in SCr to X1.5 times baseline, whichis known or presumed to have occurred withinthe prior 7 days; presumed to have occurred withinthe prior 7 days; orKUrine volume o0.5 ml/kg/h for 6 hours.orKUrine volume o0.5 ml/kg/h for 6 hours. Test patients at increased risk for AKI with measurements of SCr and Test patients at increased risk for AKI with measurements of SCr and urine output to detect AKI. ( Not Graded )urine output to detect AKI. ( Not Graded ) Individualize frequency and duration of monitoring based on patient Individualize frequency and duration of monitoring based on patient risk and clinical course. ( Not Graded )risk and clinical course. ( Not Graded ) Evaluate patients with AKI promptly to determine the cause, with Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes.(Not Graded ) special attention to reversible causes.(Not Graded ) he cause of AKI should be determined whenever possible. ( he cause of AKI should be determined whenever possible. (Not Not GradedGraded) )Definition and staging of AKIOverview of AKI, CKD, and AKD. Overlapping ovals show the Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.disorders; AKI, acute kidney injury; CKD, chronic kidney disease.AKDacute kidney diseases and disorder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%GFR60ml/min/1.73m2, 3个月肾损伤3个月AKI/CKD/AKD肾功能改变肾功能改变肾脏结构改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR 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%GFR60ml/min/1.73m2, 3个月75岁CKD(eGFR3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URR65%或eKt/V1.2，或者进行每日透析(1B)CRRT剂量We recommend delivering an effluent volume of 2025 ml/kg/h for CRRT in AKI (1A) . This will usually require a higher prescription of effluent volume. (Not Graded )顽固性高钾血症顽固性高钾血症6.5mmol/L血尿素氮血尿素氮27mmol/L难以纠正的代谢性酸中毒难以纠正的代谢性酸中毒PH7.15难以纠正的电解质紊乱难以纠正的电解质紊乱:低钠血症、低钠血症、高钠血症或高钙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肿瘤溶解综合症伴有的高尿酸血症和高磷酸盐血症高磷酸盐血症尿素循环障碍和有机酸尿症导致的高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氨血症和甲基丙二酸血症尿量尿量0.3 ml/kg/h 持续持续24h或者无尿或者无尿12hAKI伴有多器官功能衰竭伴有多器官功能衰竭难以纠正的容量负荷过重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，累及终末器官：心包炎，脑病，神经病变，肌病和尿毒症出血肌病和尿毒症出血需要输注血制品和静脉营养需要输注血制品和静脉营养重度中毒或药物过量重度中毒或药物过量严重的低体温或高体温严重的低体温或高体温临床适应症临床适应症生化指标适应症生化指标适应症RRTRRT开始指征开始指征 (1B)(1B)Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balanceexist. ( Not Graded)早期应用RRT治疗？“早”：定义不统一BUN21.5mmol/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Ccr27mmol/L开始RRT，死亡风险翻倍危重病人伴有危重病人伴有AKI时时CRRT与与IHD的利弊的利弊CRRT与IHD相比具备以下优点：稳定的血流动力学，缓慢、连续性清除液体和溶质，溶质清除率高; 持续稳定地控制氮质血症及电解质和水盐代谢;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; 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。当AKI作为多脏器功能衰竭的一部分，需要提前进入肾脏替代治疗(1C)AKI患者临床症状改善并出现肾功能恢复的早期征象应适当推迟RRT(1D)过早行RRT带来的问题静脉血栓的形成导管相关性感染抗凝治疗导致的出血其他并发症CRRT与利尿剂 We suggest not using diuretics to enhance kidney function recovery, or to reduce the duration or frequency of RRT. ( 2B)Typical setting of different RRT modalities for AKI (for 70-kg patient)We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients. (2B)Guideline12：对医学生的培养AKI预防预防诊断诊断治疗治疗Thanks！