KDIGO-AKI急性肾损伤诊疗指南解读2012版

KDIGO,2012急性肾损伤诊疗指南解读KDIGOClinicalPracticeGuidelineforAcuteKidneyInjury,2012赵良斌KDIGO：KidneyDiseaseImprovingGlobalOutcomes2012-KDIGO指南解读KDIGO,2012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（AcuteKidneyInjury,AKI）。●AKI覆盖的肾损伤WarnockDG.JAmSocNephrol16:3149-3150,2006BiesenWVetal.CJASN.2006GFR正常伴肾脏损伤的标志物改变GFR开始下降GFR明显异常KDIGO,2012AboutAKIguideline•ADQI：2002,RIFLE•AKIN：2005,modifieddefinitionandstagingsystem•KDIGO:2011,FirstclinicalguidelineforAKI–Waitingforpublishedinthissummer•AKIguidelineforAKI:2011–UKRenalAssociationFinalVersion08.03.11•AKIguidline—KDIGO2012–KDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryKDIGO,2012AKI流行病学现状•患病率：1%（社区）~7.1%（医院）•人群发病率：486~630pmp/y•AKI需要RRT发病率：22~203pmp/y•医院获得AKI死亡率：10~80%•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%KDIGO,2012指南推荐强度QualityofevidenceA－HighB－ModerateC－LowD－VerylowStrengthofrecommendationLevel1－strongLevel2－weakordiscretionaryKDIGO,2012指南推荐强度KDIGO,2012Guideline1：AKI的定义与分期符合以下情况之一者即可被诊断为AKI：①48小时内Scr升高超过26.5μmol/L(0.3mg/dl)；②Scr升高超过基线1.5倍—确认或推测7天内发生；③尿量＜0.5ml/（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KDIGO,2012AKI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)KDIGO,2012RIFLE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。BellomoR,etal.CritCare2004;8:R204-R212KDIGO,2012DeathDeathConceptualModelforAKIComplicationsComplicationsNormalNormalIncreasedriskIncreasedriskAntecedentsIntermediateStageAKIOutcomesDamageDamageGFRGFRKidneyfailureKidneyfailureStagesdefinedbycreatinineandurineoutputaresurrogatesMarkerssuchasNGAL,KIM-1,andIL-18aresurrogatesGFRDamageConceptualmodelforAKIKDIGO,2012Guideline2：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)2.224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)KDIGO,2012Chapter2.2:RiskassessmentKDIGO,2012Chapter2.2:RiskassessmentKDIGO,2012AKIisdefinedasanyofthefollowing(NotGraded):·AKIisdefinedasanyofthefollowing(NotGraded):KIncreaseinSCrbyX0.3mg/dl(X26.5lmol/l)within48hours;·orKIncreaseinSCrtoX1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;·orKUrinevolumeo0.5ml/kg/hfor6hours.TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)hecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)DefinitionandstagingofAKIKDIGO,2012OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.KDIGO,2012AKDacutekidneydiseasesanddisorder•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%–GFR60ml/min/1.73m2,3个月–肾损伤3个月KDIGO,2012AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR60ml/min/1.73m23个月3个月AKDAKI3个月内在原来基础上，GFR下降35%或Scr上升50%GFR60ml/min/1.73m2,3个月3个月NKD无异常KDIGO,2012Guideline3：PreventionandTreatmentofAKI3.1评估危险因素(1B)•年龄75岁•CKD(eGFR60ml/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)HIGHRISKKDIGO,20123.3造影剂肾病评估危险因素评估容量状态造影前水化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-AKIKDIGO,2012Guideline4：AKI的治疗一般治疗(1A)KDIGO,2012Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIKDIGO,2012补液治疗•Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)•Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)•Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)KDIGO,2012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KDIGO,2012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KDIGO,2012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againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA2002;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ2006;333(7565):420-425KDIGO,2012Chapter3.4:TheuseofdiureticsinAKI•WerecommendnotusingdiureticstopreventAKI.(1B)•WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)KDIGO,2012Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;KDIGO,2012Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia2010;65:283–293withpermissionfromJohnWileyandSons193;KDIGO,2012TheuseofdiureticsinAKI•Atpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortal