crrt影響aki殘余腎功能嗎？

1、CRRT影響AKI殘余腎功能嗎？,,Outline,AKI 的流行病學(xué)殘余腎功能的概念及臨床意義CRRT對(duì)殘余腎功能的影響及可能機(jī)制小結(jié),ARF的現(xiàn)狀-發(fā)生率逐年增加,Community-based incidence rates (per 100 000 person-years) of non dialysis requiring ARF by calendar year,Kidney Int, 2007; 72(2): 20

2、8–212,Community-based incidence rates (per 100 000 person-years) of dialysis-requiring ARF by calendar year,ARF病死率居高不下,J Am Soc Nephrol, 2006; 17: 1143–1150,ARF、ARF-D的發(fā)病率仍呈上升趨勢(shì)ARF病死率隨時(shí)間盡管呈下降趨勢(shì)，但是仍然高達(dá)25-40%,Prospective

3、observational study September 2000 to December 2001 at 54 hospitals in 23 countriesOf 29 269 critically ill patients admitted during the study period, 1738 (5.7%;95% CI 5.5%-6.0%) had ARF during their ICU stay, includi

4、ng 1260 who were treated with RRT,JAMA. 2005;294:813-818,The criteria for ARF：少尿(12小時(shí)<200ml)或/和血尿素氮高于84 mg/dL (30 mmol/L),Mortality with acute kidney failure,JAMA. 2005;294:813-818,Overall hospital mortality was 60.3

5、%,RIFLE criteria :incidence and associated mortality,Critical Care 2006, 10:R73,5383 critically ill patients in 7 ICUs, AKI occurred in 67% of patientsMortality : hazard ratio of 2.7,Has mortality from acute renal failu

6、re decreased?,,The American Journal of Medicine (2005) 118, 827–832,Reported mortality rates of patients with acute renal failure from 1956 to 2003--A systematic review of the literature - 47years80 were included in our

7、 review with a total of 15 897 patients,,Epidemiology of AKI,Blood Purif 2011;31:159–171,Multicenter Italian Study,,RIFLE-Based Data,Outline,AKI 的流行病學(xué)殘余腎功能的概念及臨床意義CRRT對(duì)殘余腎功能的影響及可能機(jī)制小結(jié),殘余腎功能(Residual renal function RR

8、F),定義：是指腎臟受到損傷后健存腎單位的殘留功能，包括清除毒素、調(diào)節(jié)水電解質(zhì)和酸堿平衡以及多種內(nèi)分泌功能,殘余腎功能與生存率,Nephrol Dial Transplant 2005;20: 396–403Nephrol Dial Transplant. 2011;26(9):2978-83.,,殘余腎功能與AKI長(zhǎng)期預(yù)后正相關(guān),,Intensity of Renal Support不改善AKI病死率,N Engl J Med 20

9、08;359:7-20.,N Engl J Med 2009;361:1627-38.,,,Once an organ is injured Try and assist a failing organ by treating the underlying causeTry to force that organ to work harder may not be the best approachRest t

10、he injured organ should be sensibleAvoid significant adverse events,Critical Care 2012, 16:317,在維持性透析患者中影響RRF的因素,血壓年齡 性別 種族 藥物鈣磷代謝脂質(zhì)代謝內(nèi)分泌激素水平腎臟替代治療相關(guān)因素（腹膜透析or血透、透析膜等）其他,J Am Soc Nephrol. 2000 Mar;11:556-64.

11、,Outline,AKI 的流行病學(xué)殘余腎功能的概念及臨床意義CRRT對(duì)殘余腎功能的影響及可能機(jī)制小結(jié),CRRT特點(diǎn),穩(wěn)定的血流動(dòng)力學(xué)持續(xù)穩(wěn)定的控制氮質(zhì)血癥和水電/酸堿平衡能夠不斷清除循環(huán)中的毒素或中分子物質(zhì)按需提供營(yíng)養(yǎng)補(bǔ)充和藥物治療,CRRT vs IRRT,Recovery of renal function --In theory,Nephrology Dialysis Transplantation 1997;12(

12、5):870–2,,,,,Compared to IRRT, CRRT can help to raise MAP,,The Cochrane Library 2008, Issue 3,,CRRT decreases the requiring of pressor,The Cochrane Library 2008, Issue 3,,CRRT is associated with more stable haemodynamics

13、 than IRRT,Retrospective cohort study Pats with ARF and required dialysis between April 1,1996, and March 31, 19992 ICU in Canada.N=261,CRRT對(duì)ARF腎功能恢復(fù)的影響－CRRT促進(jìn)腎功能恢復(fù),Crit Care Med 2003; 31:449 –455,CRRT：腎功能恢復(fù),32 ICU，n

14、=22021102 Survived 90 daysCVVH：944（85.7%）IHD：158（14.3%）,Intensive Care Med (2007) 33:773–780,慢性透析8.3%,慢性透析16.5%,944 CRRT,1102 存活90天,78 90天內(nèi) 慢性透析,26 90天內(nèi) 慢性透析,,,158 IHD,結(jié)論：CRRT更有利于腎功能的恢復(fù)，但病死率無差異。,CRRT：腎功能恢

15、復(fù),1218 patients for ARF in 54 ICU in 23 countries,Int J Artif Organs 2007; 30 (4) : 281-292,腎功能恢復(fù),CRRT能促進(jìn)腎功能恢復(fù),,DesignRetrospective cohort study32 Swedish ICUs2,202 patients with ARF (exclude ESRD),Intensive Care Med.

16、 2007, 33:773–780,VA/NIH Acute Renal Failure Trial Network (ATN) Study,1124 patients 27 sites 3 years,Intensive Management Strategy(561 patients),Randomization,,Less Intensive Management Strategy(563 patients),,,,N

17、 Engl J Med 2008;359:7-20,No difference on 60 days mortality,Kaplan–Meier Plot of Cumulative Probabilities of Death,Very high rate of intradialytic hypotension in the IHD group – compared to CRRT/SLED treatments: Twice

18、as many IHD treatments required increased vasopressor supportSix times as many IHD treatments had to be stopped Renal recovery rate was lower than expected (~50% at 28 days) – possibly related to hypotension during I

19、HD,ATN Trial: Important Results,Debate of recovery of renal function -- Results of Meta analysis,Meta analysis shows no difference in mortality and chronic dialysis dependence of patient

20、s with ARF among CRRT, IRRT or SLED,JAMA. 2008;299(7):793-805,Safety,CRRTRequire continuous anticoagulationTime is longer,IRRTRapid fluid and solute removel,BleedingDepletion of nutrientsInfection,,,HypotensionArrh