(精编)【持续性肾脏替代治疗CRRT英文精品课件】When to Start RRT in AKI.pptVIP

When to Start RRT in AKI Alexander Usorov, MD 2/24/09 New Diagnostic Criteria for AKI Acute Dialysis Quality Initiative Plus several Critical Care Societies Equals Acute Kidney Injury Network or AKIN The fundamental goal is to improve the outcomes for patients who are at risk The first AKIN conference was held in Amsterdam in September 2005 Focused on the development of uniform standards for definition and classification of AKI RIFLE-AKI Indications for RRT in AKI Volume overload unresponsive to diuretics Metabolic acidosis refractory to medical management Intoxication with dialyzable drug or toxin Uremic symptoms Encephalopathy Pericarditis Uremic bleeding Progressive azotemia in the absence of specific symptoms Cont RCTs Conger et al conducted a study on US Naval Hospital Ship USS Sanctuary between April and October of 1970 18 patients with post-traumatic AKI Intensive HD arm with pre-HD BUN70 and SCr 5 Non-intensive regimen with delaying HD until BUN approached 150 and SCr approached 10 or if clinically indicated Survival - 5/8 pts (64%) vs 2/10 (20%) pts Major complications (Gram-neg. sepsis, hemorrhage) were less freq in intensive arm Increased Mortality in Early HD Gillum et al examined 34 pts at University of Colorado in 1986 Pts were paired and randomly assigned once SCr reached 8 Intensive regimen with pre-HD BUN60 and SCr 5 Less intensive regimen: BUN and SCr reached 100 mg/dL and 9 mg/dL Average time from AKI to HD: 5+2 vs 7+3 days Higher mortality in the intensive HD group Conventional wisdom In the absence of uremic symptoms, start hemodialysis if BUN is around 100 mg/dL No additional benefit seen with earlier HD initiation nor more intensive HD prescription Moving On Further studies focused mostly on the timing of initiation of CRRT Gettings et al published a retrospective analysis of 100 consecutive patients with post traumatic AKI in 1999 Early vs late initiation based on BUN or 60 mg/dL at initiation of therapy Cont. Early group CRRT initi