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1、Renal Replacement Therapy (RRT) 腎替代性治療,By R4董國盈,Acute Kidney Injury (AKI) Acute Renal Failure ARF,Prevention,Identification of high-risk patients for pharmacologic agents-induced nephrotoxicity iodinated radiocontrast medium, NSAIDs Aggressive surveillance for nephrotoxin-induced renal dysfunction c
2、isplatin, amphotericin B, aminoglycoside Use of volume expansion in selected clinical settings Hyperpigmenturia: hemoglobinuria, myoglobinuria Crystaluria: uric acid, acyclovir, methotrexate, sulfonamides Minimalization of catheters use to avoid nosocomial sepsis,Etiology Treatment,Correct postrenal
3、 factor Correct prerenal factor Treat underlying sepsis Stop nephrotoxic drugs,Evaluation of intravascular volume,Guide of Volume Expansion,CVP 8-14 cm H2O PAWP 12-16 mmHg Urine output 0.5-1.0ml/kg/hour Weighing the patient daily Insensible water loss from the skin and respiratory tract (500 ml/day)
4、,Conservative Measurement,Fluid balance Careful monitoring of I/O and body weight Fluid restriction (usually less than 1 L/day in oliguric ARF) Total intake 15 hyperphosphatemia Treat hypocalcemia only if symptomatic,Uremia-nutrition Restriction protein but maintain caloric intake Carbohydrate 100gm
5、/day to minimize ketosis and protein catabolism Drug Review all medication, Stop magnesium-containing medication Adjusted dosage for renal failure, Readjust with improvement of GFR,Conservative Measurement,Dietary modification,Total caloric intake 35 50 kcal/kg/day to avoid catabolism Salt restricti
6、on 24 g/day Potassium intake 40 meq/day Phosphorus intake 800 mg/day,Renal Replacement Therapy,Indications for Renal Replacement Therapy,Prophylactic dialysis: BUN 80-100 mg/dl , creatinine 8-10 mg/dl Volume overloading with refractory to diuretics Pulmonary edema Hyperkalemia 6.5 mEq/l Severe metab
7、olic acidosis 7.1 Uremic pericarditis Uremic encephalopathy: coma, seizure Acute uric acid nephropathy,Methods for Renal Replacement Therapy,Intermittent hemodialysis Peritoneal dialysis Continuous renal replacement therapy: CAVH/CAVHD/CVVHDF, CVVH/CVVHD/CVVHDF,Mechanisms,Diffusion: movement of solu
8、te towards the same concentration on each side of membrane. Convection: solute is carried together with solvent across the membrane by filtration. Ultrafiltration: plasma water and crystalloids separated from the whole blood across a semipermeable membrane in response to a TMP. Osmosis: operates in
9、peritoneal dialysis. ( glucose is the osmotic agent ),Dialysis,Ultrafiltration,Intermittent hemodialysis in ARF and critically ill patients,Peritoneal dialysis,Infusion of pyogen-free solution into the peritoneal cavity, drained in subsequent cycles. Mechanism: diffusion, convection, and osmotic ult
10、rafilation Indications: patients at risk of bleeding fluid overload in CV instability,Peritoneal dialysis,Continuous renal replacement therapy (CRRT),連續性腎替代性治療,急性腎衰竭仍是重症病患常見併發症之一，且死亡率極高( 50%) 重症病患常合併有低血壓，血行動力不穩，多重器官衰竭；且常需大量輸液 (升壓劑, 輸血) 合併急性腎衰竭需透析時常合併 (1) 血行動力不穩定 (2) 大量輸液無法依需要給予（如TPN) CRRT提供另類腎替代療法的選
11、擇，並可避免傳統間歇性血液透析(intermittent hemodialysis, IHD)執行上的缺點,CRRT,CRRT種類,連續性動脈靜脈血液過濾術 (CAVH) Continuous arteriovenous hemofiltraton 連續性靜脈靜脈血液過濾術 （CVVH） Continuous venous-venous hemodialysis 連續性動脈靜脈血液透析術 （CAVHD） 連續性靜脈靜脈血液透析術 （CVVHD） Continuous venous-venous hemodialysis 連續性動脈靜脈血液透析過濾術（CAVHDF） 連續性靜脈靜脈血液透析過濾術
12、（CVVHDF） Continuous venous-venous hemodiafiltration,CAVH,CVVH,CRRT的適應症,A. Renal indications -hemodynamic instability -multiple organs dysfunction syndrome accompanied by renal failure -acute renal failure with cerebral edema B. Non-Renal indications -possible removal of substances active as mediator
13、s,適應症,(1) 急慢性腎衰竭及血壓不穩定休克患者之併發症。 (2) 呼吸窘迫症候群。 (3) 多重器官衰竭。 (4) 鬱血性心衰竭、或肝衰竭。 (5) 敗血性休克。 (6) 燙傷併血壓不穩。 (7) 器官移植後急性腎衰竭。 (8) 毒藥物中毒。,CRRT 的優點,Avoidance of electrolyte, water and urea fluctuation Gradual urea removal Hemodynamic stability with slow ultrafiltration Optimal fluid balance and unlimited alimenta
14、tion Elimination of septic mediators Lower intracranial pressure Improved outcome,CRRT的缺點,出血危險性（常需使用抗凝劑） limited mobility slower solute and fluid removal,MMH CRRT Order,Modality: (CVVH, CVVHD, CVVHDF) AK priming: N/S 500 cc x 2 BT aa heparin 0.5 cc Anticoagulation: Prepare Heparin 12,500U + N/S 500c
15、c IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed aPTT hold dose (ml/h) 2.5x 60mins - 4 If non-heparin, N/S ( 250 ) cc Q30mins to rinse the AK,Predilution: run 999 cc/hr alternately as followed via artery end 1st bottle N/S 500cc + Sinca 1amp 2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd
16、bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp Dialysate: 1.5% PD solution run 999 cc/hr Warm Predilution Mg QW1,4 aPTT Q12H KCl supplement:,MMH配方 (Predilution),Predilution run 500cc/hr alternately as followed via artery end: 1st bottle N/S 500cc + Sinca 1amp 2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D/W 500cc + NaHCO3 5amp,KCl Supplement,CRRT結語,連續性腎替代療法提供另一種治療選擇，特別在急性腎衰竭病患併有血行動力狀態不穩，輸液之
