KDIGO-AKI急性肾损伤诊疗指南解读2012版

急性肾损伤诊疗指南解读,KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012,赵良斌,KDIGO：Kidney Disease Improving Global Outcomes,2012-KDIGO指南解读,急性肾损伤(AKI)与急性肾衰竭(ARF),国际肾脏病和急救医学界将ARF 改为急性肾损伤（Acute Kidney Injury, AKI）。AKI 覆盖的肾损伤,Warnock DG. J Am Soc Nephrol 16:3149-3150,2006Biesen WV et al. CJASN. 2006,About AKI guideline,ADQI：2002, RIFLEAKIN：2005, modified definition and staging systemKDIGO: 2011, First clinical guideline for AKIWaiting for published in this summerAKI guideline for AKI :2011UK Renal Association Final Version 08.03.11AKI guidlineKDIGO 2012KDIGO Clinical Practice Guideline for Acute Kidney Injury,AKI流行病学现状,患病率：1%（社区） 7.1%（医院）人群发病率：486630 pmp/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,Guideline 1：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(0.3 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,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,Conceptual model for AKI,Guideline 2：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 assessment,Chapter 2.2: Risk assessment,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; ·or KIncrease in SCr to X1.5 times baseline, whichis known or presumed to have occurred withinthe prior 7 days; ·orKUrine volume o0.5 ml/kg/h for 6 hours.Test patients at increased risk for AKI with measurements of SCr and urine output to detect AKI. ( Not Graded )Individualize frequency and duration of monitoring based on patient risk and clinical course. ( Not Graded ) Evaluate patients with AKI promptly to determine the cause, with special attention to reversible causes.(Not Graded ) he cause of AKI should be determined whenever possible. (Not Graded),Definition and staging of AKI,Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and 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%GFR<60ml/min/1.73m2, <3个月肾损伤<3个月,AKI/CKD/AKD,Guideline 3：Prevention and Treatment of AKI,3.1评估危险因素(1B)年龄>75岁CKD (eGFR<60ml/min/1.73m2心力衰竭动脉粥样硬化性周围血管病变肝脏疾病糖尿病肾毒性药物的使用低血容量感染3.2评估容量状态后适当补液(1B),HIGHRISK,3.3造影剂肾病,3.4继发于横纹肌溶解的AKI给予0.9%氯化钠和碳酸氢钠扩容(1B),对具CI-AKI高风险者：建议采用等渗或低渗造影剂建议口服或静脉使用N -乙酰半胱氨酸（NAC）及等渗晶体预防CI-AKI推荐使用等渗氯化钠或碳酸氢钠静脉扩容以预防CI-AKI,Guideline 4：AKI的治疗,一般治疗(1A),Stage-based management of AKI,Chapter 2.3:Evaluation and general management ofpatients with and at risk for AKI,补液治疗,In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion ofintravascular volume in patients at risk for AKI or with AKI. (2B)We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for AKI. ( 1C) We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting (2C) or in patients with septic shock (2C),补液治疗：低血容量者： 重复小剂量补液(250ml晶体液/胶体液） 密切监测CVP和尿量 监测乳酸和碱剩余水平严重脓毒血症者： 慎用高分子量羟乙基淀粉,药物治疗(1B),多脏器功能衰竭药代动力学改变（分布容积、清除、与蛋白结合）需要调整药物剂量,目前无特殊的药物用于治疗继发于低灌注损伤/脓毒血症的AKI (1B),袢利尿剂,against,Mehta RL, Pascual MT, Soroko S et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002; 288: 2547-2553 Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333 (7565): 420-425,Chapter 3.4: The use of diuretics in AKI,We recommend not using diuretics to prevent AKI. (1B)We suggest not using diuretics to treat AKI, exceptin the management of volume overload. ( 2C),Effect of furosemide vs. control on all-cause mortality. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283293 with permission from John Wiley and Sons193;,Effect of furosemide vs. control on need for RRT. Reprinted from Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010; 65: 283293 with permission from John Wiley and Sons193;,The use of diuretics in AKI,At present, thecurrent evidence does not suggest that furosemide can reduce mortality in patients with AKI.a beneficial role for loop diuretics in facilitatingdiscontinuation of RRT in AKI is not evident.,甘露醇,mannitol is not scientifically justified in the prevention of AKI.,Vasodilator therapy: dopamine,fenoldopam, and natriuretic peptides,