1、ICU中的血液凈化指南之我見ICUICU中的血液中的血液(xuy)(xuy)凈化指南之我見凈化指南之我見第一頁，共四十二頁。ICU中的血液凈化指南之我見ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions56第二頁，共四十二頁。ICU中的血液凈化指南之我見Introductionv Methods of extracorporeal renal replacement therapy (RRT) have been used for the supportive treatment of AK

2、I for over 60 years.v CRRT for the critically ill patient with ARF was introduced in 1977 by Kramer et al. v Since then, many studies have reported on CRRT in the critically ill.Klin Wochenschr 1977;55:1121-1122.第三頁，共四十二頁。ICU中的血液凈化指南之我見Introductionv But for several reasons comparison among studies i

3、s difficult: vVarious treatment modalities have been applied in heterogeneous populations. vDifferences in clinical setting and underlying molecular biological mechanisms that initiate and maintain ARF. vFurthermore, more than 35 definitions of ARF.v Practice patterns vary widely between individual

4、centers.v Up to now, there are no standard guidelines for the application of CRRT in critically ill patients.Curr Opin Crit Care 2002;8:509-514.第四頁，共四十二頁。ICU中的血液凈化指南之我見Introductionv The RIFLE Classification for acute renal failure Crit Care 2004;8:R204-R212.第五頁，共四十二頁。ICU中的血液凈化指南之我見IntroductionvConcl

5、usions:v More then 200 different definitions of ARF and about 90 RRT start criteria were reported. Oliguria and RIFLE were the most frequent criteria used to define ARF. RIFLE criteria might show a clinical impact on future daily practice and research.v Different RRT techniques are available in most

6、 centers, but a general lack of treatment dose standardization is noted by our survey. v Non-renal indications to RRT still need to find a definitive role in routine practice.Nephrol Dial Transplant (2006) 21: 690696第六頁，共四十二頁。ICU中的血液凈化指南之我見v In the past, the interaction between nephrology and intens

7、ive care was minimal.v Today, there is continuous interaction with several moments of high interaction due to common patients and complex syndromes, and much of the treatment of AKI has moved from the renal ward into ICUs. IntroductionContrib Nephrol. Basel, Karger, 2010 (166):13第七頁，共四十二頁。ICU中的血液凈化指

8、南之我見ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose or intensity of CRRT4Conclusions56第八頁，共四十二頁。ICU中的血液凈化指南之我見Type of therapyClassification of blood purification in critical care (BPCC) technologyPMX = polymyxin-B immobilized fiber; PMMA = polymethylmethacrylate; PAN = polyacrylonitrile; P

9、EPA = polyether polymer alloyContrib Nephrol. Basel, Karger, 2010(166):1120第九頁，共四十二頁。ICU中的血液凈化指南之我見Type of therapyv As a continuous therapy, CRRT can be rapidly tailored to changes in a patients clinical condition during critical illnessBlood purification in critical careContrib Nephrol. Basel, Karg

10、er, 2010(166):1120HDF = hemodiafiltration第十頁，共四十二頁。ICU中的血液凈化指南之我見Type of therapyv These advantages have contributed to the widespread uptake of CRRT as the first-choice RRT in ICUs throughout Australia, Japan and Europe.v In these regions, CRRT is usually initiated and managed within the ICU, with R

11、RT being integrated with other aspects of the management of critical illnessNat. Rev. Nephrol. 2010:6:521529.第十一頁，共四十二頁。ICU中的血液凈化指南之我見Type of therapyv In north America, however, traditional structures of ICU management favor an open-ICU approach:Within this model, RRT is usually prescribed by a neph

12、rologist in the ICU and is initiated by a dialysis nurse In this environment, IHD has the advantage of requiring only daily or alternate-day attendance by the renal team Conversely, the relative labor costs of providing CRRT are increased, an effect that is compounded by the larger fixed costs and h

13、igher consumable requirements of CRRTv These logistic factors have led to a preference for IHD over CRRT being maintained in ICUs that use the north American.Nat. Rev. Nephrol. 2010:6:521529.第十二頁，共四十二頁。ICU中的血液凈化指南之我見Type of therapyv Clinical studies of CRRT in the ICUv The diversity of clinical appr

14、oaches to the treatment of AKI in the ICU is illustrated by the results of the BEST Kidney study, The multinational epidemiological study of RRT practice in the ICU Study documented the treatment of AKI in 1,738 patients in 54 ICUs on five continentsNat. Rev. Nephrol. 2010:6:521529.第十三頁，共四十二頁。ICU中的血

15、液凈化指南之我見Type of therapyvBEST study resultsCRRT was the most common choice of initial RRT treatment, with 80% of patients on CRRT; IHD use was mostly restricted to ICUs in north and south America, where it was used as initial therapy in 3040% of patients, while, by contrast, CRRT is used first in 100

16、% of ICUs in Australia.Among patients receiving CRRT, however, marked variation in the modality, intensity, timing was observed Making it difficult to compare outcomes between patients on CRRT and those on IHDNat. Rev. Nephrol. 2010:6:521529.第十四頁，共四十二頁。ICU中的血液凈化指南之我見Type of therapyNat. Rev. Nephrol.

17、 2010:6:521529.第十五頁，共四十二頁。ICU中的血液凈化指南之我見v 有些研究表明在有些研究表明在ICU不穩定的患者中應用不穩定的患者中應用IHD也不會存在也不會存在(cnzi)明顯的明顯的問題問題, 有有RCTs并沒有顯示出并沒有顯示出CRRT優于優于IHDType of therapyKidney Int 2009,76:422-427.BMC Nephrol 2010, 11:32.Nephrol Dial Transplant 2009, 24:512-518.Lancet 2006,368:379-385. 對于對于(duy)依賴血管活性藥物的依賴血管活性藥物的AKI患

18、者，患者，CRRT才是最適合的；才是最適合的； 依賴血管活性藥物的依賴血管活性藥物的AKI患者將來接受長期透析的幾率患者將來接受長期透析的幾率CRRT 間斷性治療；間斷性治療； AKI的急性期推薦應用的急性期推薦應用CRRT，尤其是對于嚴重血流動力學不穩定、需大量清除液，尤其是對于嚴重血流動力學不穩定、需大量清除液體以便于進行更有效藥物治療的患者。體以便于進行更有效藥物治療的患者。Crit Care Med 2008, 36:610-617.Kidney Int 2009,76:422-427.Nat Rev Nephrol 2010, 9:521-529.Clin Pharmacol The

19、r 2009, 86:562-565.v 目前目前(mqin)共識：共識：第十六頁，共四十二頁。ICU中的血液凈化指南之我見ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions56第十七頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv The right time to start RRT is still a topic of debate.v 主要的原因的是：主要的原因的是：沒有一個明確的、協商一致的沒有一個明確的、協商一致的AKI定義能夠根據腎損傷程度對患者進行

20、分級定義能夠根據腎損傷程度對患者進行分級研究時很難獲得同種類相同特征的患者組人群研究時很難獲得同種類相同特征的患者組人群v RIFLE和和AKIN分級標準分級標準(biozhn)使對于使對于AKI的研究向前邁進了一大步的研究向前邁進了一大步v 兩種分級標準均能使臨床醫生警惕兩種分級標準均能使臨床醫生警惕AKI的出現，進行早期干預的出現，進行早期干預Crit Care 2009, 13:211.第十八頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv There is significant variation in the timing of initiation of

21、 RRT, with up to two-fold differences in the reported values of BUN, creatinine, or urine output at RRT initiation.Clinical studies evaluating the timing of initiation of CRRT in critically ill patients第十九頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv In the above-mentioned studies there is a clear trend tow

22、ard a better outcome with earlier timing of RRT. vIn the absence of large RCTs comparing early to late initiation of RRT, no firm overall recommendations for timing of RRT can be made. 第二十頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv 目前目前(mqin)廣為接受的廣為接受的Septic AKI開始開始RRT時機，尤其是在時機，尤其是在septic shock 時：時：RIFLE

23、injury stage (or AKIN stage 2) v but consensus on this topic awaits results from large-scale RCTs.第二十一頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv 除除AKI外，患者的一些其他情況也需要行早期外，患者的一些其他情況也需要行早期RRT治療：治療：vmainly pediatric, treated by ECMO for severe ARDS.vFluid overload definitely plays a role in timing, because CR

24、RT proved successful in patients without AKI but refractory to diuretics. v 治療時機的標準在不斷治療時機的標準在不斷(bdun)發展，包括：發展，包括：vseverity of organ dysfunction (SOFA score)；vseverity of AKI (RIFLE or AKIN stage)；vfluid overload status； vtime from admission；vbiomarker use, etc.v 但他們在日常臨床實踐中的應用價值仍然需要評估但他們在日常臨床實踐中的應用

25、價值仍然需要評估Kidney Int 2010, 77:469-470.Kidney Int 2009, 76:1289-1292J Am Soc Nephrol 2011, 22:810-820.第二十二頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv When initiation of RRT is considered, it is important to realize that:v the consequences of ureamic toxicity, metabolic acidosis and/or fluid overload are like

26、ly to be more severe in the critically ill patient. v Moreover, renal function is unlikely to recover within a short period during persistent and severe failure of other organs. v Furthermore, various inflammatory mediators are cleared by the kidney.第二十三頁，共四十二頁。ICU中的血液凈化指南之我見Timing of CRRTv 最近最近(zuj

27、n)的一項前瞻性研究和兩項的一項前瞻性研究和兩項meta-analysis明確地支持明確地支持early timingThe findings of these studies support earlier initiation of acute RRTIn the absence of new evidence from suitably-designed randomised trials, a definitive treatment recommendation cannot be made第二十四頁，共四十二頁。ICU中的血液凈化指南之我見ContentsIntroduction1

28、 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions56第二十五頁，共四十二頁。ICU中的血液凈化指南之我見Dose or intensity of CRRT第二十六頁，共四十二頁。ICU中的血液凈化指南之我見Dose or intensity of CRRT第二十七頁，共四十二頁。ICU中的血液凈化指南之我見Dose or intensity of CRRTv Both the ATN and RENAL studies failed to detect any survival benefit from more-intensiv

29、e RRT And no significant differences in mortality rates were observed between high-intensity and low-intensity treatment in subgroups in either study.These results provide definitive evidence to recommend that escalation of CRRT intensity to beyond conventional doses of 25 ml/kg/h is not beneficial

30、for unselected ICU patients with AKI.Possible relationship between delivered dose of CRRT and survival, with results from the ATN and RENAL trials illustrated. 第二十八頁，共四十二頁。ICU中的血液凈化指南之我見Dose or intensity of CRRTv而關于而關于(guny)non-septic AKI 的治療劑量，的治療劑量，RENAL研究得到了一個明確的答案研究得到了一個明確的答案:v Randomized Evalua

31、tion of Normal versus Augmented Levels (RENAL) study: vno beneficial effect of CVVHDF at 40 ml/kg/h compared with 25 ml/kg/h.v Therefore, current consensus suggests a hemofiltration dose of 25 ml/kg/h in non-septic AKI with no additional benefit from a dose increase.N Engl J Med 2009, 361:1627-1638.

32、第二十九頁，共四十二頁。ICU中的血液凈化指南之我見Dose or intensity of CRRTv 然而，然而， 需要強調的是：需要強調的是：專家的意見是患者治療劑量要足夠，至少專家的意見是患者治療劑量要足夠，至少25 ml/kg/h25 ml/kg/h。 但實際中由于存在可預測的但實際中由于存在可預測的（bags change, nursing.）和不可預測的和不可預測的（surgery, clotting.）治療中斷，意味著劑量要在治療中斷，意味著劑量要在30-35 ml/kg/h30-35 ml/kg/h；Septic AKI患者的治療劑量目前仍存在爭議，一些小的前瞻隨機研究表明患

33、者的治療劑量目前仍存在爭議，一些小的前瞻隨機研究表明高劑量的血液濾過是有益的。高劑量的血液濾過是有益的。多中心的多中心的 “IVOIRE study” (hIgh Volume in Intensive care)，在，在sepsis引起的引起的AKI，休克，休克(xik)和多臟衰患者中，比較和多臟衰患者中，比較35 ml/kg/h vs. 70 ml/kg/h ，不久，不久后，可能會對治療劑量的爭論有所定論。后，可能會對治療劑量的爭論有所定論。Joannes-Boyau O, Honore PM: Hemofiltration Study: IVOIRE Study: clinicaltri

34、 ID NCT00241228., last Accessed in June 2011.Crit Care 2009, 13:R57.J Nephrol 2011, 24:165-176.第三十頁，共四十二頁。ICU中的血液凈化指南之我見Dose or intensity of CRRTv “IVOIRE study” (hIgh Volume in Intensive care)初步初步(chb)結果：結果：Although patients included were more severely ill, overall mortality in the IVOIRE st

35、udy remains very low (39% at 28 days and 52% at 90 days) compared with the RENAL study. This may be due to the earlier start of treatment at the renal injury level.Awaiting results from this important trial, 35 ml/kg/h should remain the standard dose in septic AKI, particularly in the presence of sh

36、ock.Joannes-Boyau O, Honore PM: Hemofiltration Study: IVOIRE Study: ID NCT00241228., last Accessed in June 2011.第三十一頁，共四十二頁。ICU中的血液凈化指南之我見ContentsIntroduction1 Type of therapy2Timing of CRRT3Dose of CRRT4Conclusions56第三十二頁，共四十二頁。ICU中的血液凈化指南之我見RRT in ICU: PreferencevDecision about

37、which technique to use depends on:v1. What we want to remove from the plasma 第三十三頁，共四十二頁。ICU中的血液凈化指南之我見RRT in ICU: Preference v2. The patients cardiovascular status CRRT causes less rapid fluid shifts and is the preferred option if there is any degree of cardiovascular instability.v3. The availabili

38、ty of resourcesCRRT is more labour intensive and more expensive than IHDAvailability of equipment may dictate the form of RRT第三十四頁，共四十二頁。ICU中的血液凈化指南之我見RRT in ICU: Preference v4. The clinicians experience It is wise to use a form of RRT that is familiar to all the staff involvedv5. Other specific cli

39、nical considerations Convective modes of RRT may be beneficial if the patient has septic shock CRRT can aid feeding regimes by improving fluid management CRRT may be associated with better cerebral perfusion in patients with an acute brain injury or fulminant hepatic failure第三十五頁，共四十二頁。ICU中的血液凈化指南之我

40、見許多許多(xdu)問題懸而未決問題懸而未決第三十六頁，共四十二頁。ICU中的血液凈化指南之我見標準標準(biozhn)與個體化與個體化You are unique!Standard!第三十七頁，共四十二頁。ICU中的血液凈化指南之我見Key Pointsv It is recommended to define ARF according to the RIFLE classification system into ARFrisk, ARFinjury and ARFfailure.v It is recommended to base the decision when to start RRT not only on the severity of ARF, but also on the severity of other organ failure. v Initiation of RRT is to be considered in oliguric patients (RIFLErisk-oliguria or RIFLEinjury-oliguria), despite adequate fluid resuscitation, and/or a persisting steep rise in serum creatinine. 第三