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1、KDIGO 2012 急性肾损伤诊疗指南解读急性肾损伤诊疗指南解读 KDIGO Clinical Practice Guideline for Acute KDIGO Clinical Practice Guideline for Acute Kidney Injury 2012Kidney Injury 2012 KDIGO Kidney Disease Improving Global Outcomes 2012 KDIGO指南解读 1 1 KDIGO 2012 急性肾损伤急性肾损伤 AKI AKI 与急性肾衰竭与急性肾衰竭 ARF ARF 国际肾脏病和急救医学界将ARF 改为急性肾损伤
2、Acute Kidney Injury AKI AKI 覆盖的肾损伤 Warnock DG J Am Soc Nephrol 16 3149 3150 2006 Biesen WV et al CJASN 2006 GFR正常伴肾脏损伤的标志物改变 GFR开始下降 GFR明显异常 2 2 KDIGO 2012 About AKI guidelineAbout AKI guideline ADQI 2002 RIFLE AKIN 2005 modified definition and staging system KDIGO 2011 First clinical guideline for
3、AKI Waiting for published in this summer AKI guideline for AKI 2011 UK Renal Association Final Version 08 03 11 AKI guidline KDIGO 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury 3 3 KDIGO 2012 AKIAKI流行病学现状流行病学现状 患病率 1 社区 7 1 医院 人群发病率 486 630 pmp y AKI需要RRT发病率 22 203pmp y 医院获得AKI死亡率 1
4、0 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 4 4 KDIGO 2012 指南推荐强度指南推荐强度 5 5 KDIGO 2012 指南推荐强度指南推荐强度 6 6 KDIGO 2012 Guideline 1Guideline 1 AKIAKI的定义与分期的定义与分期 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 5 mol L 0 3 mg dl Scr 升高超过基线1 5倍 确认或推测7天内发生 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
5、和分期标准 7 7 KDIGO 2012 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 8 8 KDIGO 2012 RIFLERIFLE分级分级 2002 年急性透析质量倡议组 ADQI 制定了ARF的 RIFLE 分级诊断标准 Bellomo R et al Crit Care 2004 8 R204 R212 9 9 KDIGO 2012 Conceptual model for AKI 1010 KDIGO 2012 Guideline 2Guideline 2 临床评估 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 2 24小
6、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 1111 KDIGO 2012 Chapter 2 2 Risk assessmentChapter 2 2 Risk assessment 1212 KDIGO 2012 Chapter 2 2 Risk assessmentChapter 2 2 Risk assessment 1313 KDIGO 2012 AKI is defined as any of the following Not Graded AKI is defined as any of the following Not Graded AKI i
7、s 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 X
8、1 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 a
9、t 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 Grade
10、d 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 determin
11、ed whenever possible he cause of AKI should be determined whenever possible Not Not GradedGraded Definition and staging of AKI 1414 KDIGO 2012 Overview 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 su
12、bset 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 d
13、isease 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 1515 KDIGO 2012 AKDAKD acute kidney diseases and disorderacute ki
14、dney 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 GFR 60ml min 1 73m2 3个月 肾损伤 3个月 1616 KDIGO 2012 AKI CKD AKDAKI 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 3个月 3个月 AKDAKI 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 75岁 CKD eGFR3周 建议用皮下隧道导管 导管仅限于RR
15、T治疗时使用 1D 以预防感染 4343 KDIGO 2012 Guideline 9Guideline 9 体外抗凝 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 4444 KDIGO 2012 Guideline 10Guideline 10 RRTRRT处方处方 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
16、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 4545 KDIGO 2012 CRRTCRRT剂量剂量 We recommend delivering an effluent volume of 20 25 ml kg h for CRRT in AKI 1A This will usually require a higher prescription of effluent volume Not Graded 4646 KDIGO 2012 4747 KDIGO 2012 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 3 ml
