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1、CRRT Severe sepsis and MODS,邱海波 东南大学附属中大医院ICU 东南大学急诊与危重医学研究所,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,Mode of RRT differences among continents,Bellomo, et al. 2001,Understanding Renal Replacement Therapy and
2、Acute Renal Failure in the ICU (The B.E.S.T kidney study),Retrospective cohort study Pats with ARF and required dialysis between April 1,1996, and March 31, 1999 2 ICU in Canada. N=261,CRRT对ARF肾功能恢复的影响 CRRT促进肾功能恢复,Crit Care Med 2003; 31:449 455,IHD vs CRRT,ICU RRT n=116,RRT for overdose n=7,Pre-exis
3、ting CRF n=16,ICU RRT for ARF/MOF n=66,Initial CRRT n=66,Initial IHD n=28,Jacka MJ, Ivancinova X, Gibney RTN. Can J Anaesth 2005;52:327-332,Munns et al观察危重急性肾衰竭患者 IHD CRRT CCr下降 25% 7% 尿量下降 50% 10% 钠排泄分数下降 46% 12% 肾功能下降的原因: IHD平均动脉压下降，导致肾脏低灌注，加重肾脏缺血性损伤，延迟急性肾衰竭肾功能的恢复,为什么CRRT促进肾功能恢复?,160 pats with ARF
4、: Daily vs every-other-day IHD Mean ultrafiltration volume Daily: 1.2 0.5 L Every-other-day: 3.5 0.3 L (P 0.001). Hypotension occurred in Daily: 5 2% Every-other-day: 25 5% (P 0.001) Time to recovery of renal function Daily: 9 2 days Every-other-day:16 6 Days P = 0.001,N Engl J Med 2002; 346:305-310
5、,为什么CRRT有助于肾脏功能的恢复？,Effect of RRT dose on recovery of renal function?,P = NS,Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000; 356: 26 -30,CRRT vs IRRT on return of renal function On mortality,Mortality: Which is better CRRT or IHD?,Swzrtz. RD. Compa
6、ring continuous HF with HD in patients with severe ARF Am J Kidney 1999; 34: 424 - 432 Mehti. RL. Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF. Kidney Int 2001; 60: 1154 - 63 Kellum JA. Continuous versus intermittent RRT. A meta-analysis. Intensive Care Med
7、2002; 162: 197- 202,Conclusion :There is no conclusive evidence to support the superiority of CRRT vs IHD. Both techniques are complimentary,CRRT vs IRRT对危重病患者的影响 CRRT可降低危重病患者病死率,Quality score 5: definitely equal,CRRT vs IRRT对危重病患者的影响 CRRT可降低危重病患者病死率,Hospital mortality: CRRT was associated with a re
8、duced risk of hospital death in the six studies in which baseline severity of illness was similar RR 0.48, 0.340.69, p0.0005,Intensive Care Med, 2002, 28: 29-37,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,198919
9、97：100例创伤后ARF 早期后期的临界：BUN 60mg/dl 两组病人创伤评分、GCS、发生休克的比例、年龄、性别和创伤分布均无差异,早期后期CRRT对危重病患者的影响 早期或预防性CRRT可降低ARF患者病死率,Gettings LG. Intensive Care Med, 1999, 25: 805-813,早期后期CRRT对危重病患者的影响 早期或预防性CRRT可降低ARF患者病死率,生存率明显差异,Gettings LG. Intensive Care Med, 1999, 25: 805-813,Outcome Early start 39% survival Late st
10、art 20% survival,Early vs. Late RRT,RCT (n =106) Oliguria ( 30cc/hr) refractory to high-dose furosemide (500mg over 6hrs) Randomized to 3 groups: Early (12h) high-volume hemofiltration (n=35; 72-96L/24 h) Early (12h) low-volume hemofiltration (n=35; 24-36L/24 h) Late low-volume hemofiltration (n=36;
11、 24-36 L/24 h),Bouman et al. Crit Care Med 30:2205-2211, 2002,Dose and Timing of CVVH in ARF,Bouman CS, et al. Critical Care Med 2002; 30:2205-2211,74.3%,68.8%,75.0%,0%,20%,40%,60%,80%,100%,28-Day Survival,LV-Late,LV-Early,HV-Early,Treatment Group,n=35 SOFA 10.32.8,n=36 SOFA 10.61.9,n=35 SOFA 10.12.
12、2,1. CRRT vs IRRT 2. Early vs late CRRT 3. High vs normal flow 4.Possible ways to increase mediators clearance,Current opinion in CRRT,High-volume hemofilitration (HVHF),Ronco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT,Lancet 2000; 356: 26 -30,RCT of HVHF in Sep
13、tic Shock,5919 ICU admissions,Oliguric ARF N=248,Non-oliguric ARF N=130,Not randomized in study N=142,Randomized In study N-106,EHV n=35,ELV n=35,LLV n=36,Hemofiltration n=352,No hemofiltration N=6,Bouman CS et al. Effects of early high-volume CVVH on survival and recovery of renal function in IC pa
14、tients with ARF. Crit Care Med 2002; 30: 2205 (n=106),EHV 74.3%,LLV 75%,ELV 68.8%,ELV= Early low vol hemofiltration=1-1.5 L/hr LLV= Late low vol hemofiltration=1-1.5 L/hr EHV= Early high vol hemofiltration=3-4 L/hr,Early=within 12 hours of diagnosis of septic shock,Survival %,No difference renal rec
15、overy or 28-d mortality,160 pats with ARF: Daily vs every-other-day ID,N Engl J Med 2002; 346:305-310,Survival vs dialysis dose in IHD,CRRT: Impact on outcomes,Severity of Disease,Survival rate %,High Dose (CRRT),Low Dose (IHD),The Cleveland Clinic Observation,100,90,80,70,60,50,40,30,20,10,0,ATN (n
16、=1260),Multi-center RCT in the USA. Patients with ARF randomized to: Intensive Management Strategy: If hemodynamically stable (SOFA CVS score: 0-2) IHD 6-times/week (target Kt/V =1.2-1.4/session) If hemodynamically unstable (SOFA CVS score: 3-4) CVVHDF at 35 ml/kg/hr or SLED 6-times/week (target Kt/V = 1.2-1.4/session) Conventional Mana
