CRRT 连续肾脏替代疗法概要1.pptVIP

CRRT 山东大学齐鲁医院 田军 CRRT的目的 危重症采用CRRT的目的主要有两大类: 一是重症患者并发肾功能损害； 二是非肾脏疾病或肾功损害的重症状态，主要用于器官功能不全支持、稳定内环境、免疫调节等。 治疗时机，模式选择，治疗剂量 AKI的定义和分类　　　KDIGO推荐，符合以下情况之一者即可被诊断为AKI：① 48小时内血清肌酐（Scr）升高超过26.5 μmol/L（0.3 mg/dl）；② 7天内Scr 升高超过基线1.5倍；③ 尿量＜0.5 ml/（kg?h），且持续6小时以上。AKI分级标准见右表。　　　AKD的定义　　　在AKI指南中，KDIGO引入了AKD的新概念，即符合以下任何条件者即可被诊断为AKD：① 符合AKI标准；② 3个月内肾小球滤过率（GFR）下降超过35%或Scr升高超过50%；③ 3个月内GFR下降至60 ml/（min?1.73m2）以下；④ 肾脏损伤时间短于3个月。　  RIFLE Stratification in Patients Treated with CRRTBell et al, Nephrol Dial Transplant 2005 Conclusions: An increased treatment dose from 20 ml/h/kg to 35 ml/h/kg significantly improved survival. a dose of 35 ml/kg/hour was associated with dramatic improvement in survival of nearly 20 %. A delivery of 45ml/kg/hr did not result in further benefit in terms of survival, but in the septic patient an improvement was observed. Our data suggest an early initiation of treatment and a minimum dose delivery of 35 ml/h/kg (ex. 70 kg patient = 2450 ml/h) improve patient survival rate. CRRT vs. IHD in Renal Recovery Recent studies suggest that CRRT is superior to IHD with respect to recovery of renal function Implications go far beyond just “hard” endpoint of renal recovery Need for chronic dialysis impairs quality of life If length of stay (LOS) in ICU can be reduced this will have a major impact on hospital budget Patients dependent on chronic dialysis will consume significant health care resources and have an impact on the community health care budget Two methods of high volume hemofiltration (HVHF), with different underlying concepts and results, became prevalent: Continuous high volume hemofiltration (CHVH) providing 50 to 70 ml/kg/h 24 hours a day, intermittent high volume hemofiltration (IHVH) with brief, very high volume treatment at 100 to 120 ml/kg/h for 4 to 8 hours 血液净化治疗非肾脏病的指征 全身炎症反应综合征/脓毒症 多器官功能障碍综合征 急性呼吸窘迫综合征 挤压综合征 急性坏死性胰腺炎 严重烧伤 心肺旁路 电解质紊乱 乳酸酸中毒 肝功能衰竭 急、慢性心力衰竭 药物或毒物中毒 先天性代谢缺陷 急性肿瘤溶解综合征 连续性血液净化在SIRS和MODS中的应用 The new concept of ‘purific