1、ICUICU中的血液净化指南之我见中的血液净化指南之我见 Contents Introduction 1 Type of therapy 2 Timing of CRRT 3 Dose of CRRT 4 Conclusions 5 6 Introduction Methods of extracorporeal renal replacement therapy(RRT)have been used for the supportive treatment of AKI for over 60 years.CRRT for the critically ill patient with AR
2、F was introduced in 1977 by Kramer et al.Since then,many studies have reported on CRRT in the critically ill.Klin Wochenschr 1977;55:1121-1122.Introduction But for several reasons comparison among studies is difficult:Various treatment modalities have been applied in heterogeneous populations.Differ
3、ences in clinical setting and underlying molecular biological mechanisms that initiate and maintain ARF.Furthermore,more than 35 definitions of ARF.Practice patterns vary widely between individual centers.Up to now,there are no standard guidelines for the application of CRRT in critically ill patien
4、ts.Curr Opin Crit Care 2002;8:509-514.Introduction The RIFLE Classification for acute renal failure Crit Care 2004;8:R204-R212.Introduction Conclusions: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
5、define ARF.RIFLE criteria might show a clinical impact on future daily practice and research.Different RRT techniques are available in most centers,but a general lack of treatment dose standardization is noted by our survey.Non-renal indications to RRT still need to find a definitive role in routine
6、 practice.Nephrol Dial Transplant(2006)21:690696 In the past,the interaction between nephrology and intensive care was minimal.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 t
7、he renal ward into ICUs.Introduction Contrib Nephrol.Basel,Karger,2010(166):13 Contents Introduction 1 Type of therapy 2 Timing of CRRT 3 Dose or intensity of CRRT 4 Conclusions 5 6 Type of therapy Classification of blood purification in critical care(BPCC)technology PMX=polymyxin-B immobilized fibe
8、r;PMMA=polymethylmethacrylate;PAN=polyacrylonitrile;PEPA=polyether polymer alloy Contrib Nephrol.Basel,Karger,2010(166):1120 Type of therapy As a continuous therapy,CRRT can be rapidly tailored to changes in a patients clinical condition during critical illness Blood purification in critical care Co
9、ntrib Nephrol.Basel,Karger,2010(166):1120 HDF=hemodiafiltration Type of therapy These advantages have contributed to the widespread uptake of CRRT as the first-choice RRT in ICUs throughout Australia,Japan and Europe.In these regions,CRRT is usually initiated and managed within the ICU,with RRT bein
10、g integrated with other aspects of the management of critical illness Nat.Rev.Nephrol.2010:6:521529.Type of therapy In north America,however,traditional structures of ICU management favor an open-ICU approach:Within this model,RRT is usually prescribed by a nephrologist in the ICU and is initiated b
11、y 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 higher consumable requirements of CRRT The
12、se 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.Type of therapy Clinical studies of CRRT in the ICU The diversity of clinical approaches to the treatment of AKI in the ICU is illustrated by the results
13、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 continents Nat.Rev.Nephrol.2010:6:521529.Type of therapy BEST study results CRRT was the most common choice of initial RRT treatment,
14、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%of ICUs in Australia.Among patients receiving CRRT,however,marked variation in the modality,intensity,timi
15、ng was observed Making it difficult to compare outcomes between patients on CRRT and those on IHD Nat.Rev.Nephrol.2010:6:521529.Type of therapy Nat.Rev.Nephrol.2010:6:521529.有些研究表明在有些研究表明在ICU不稳定的患者中应用不稳定的患者中应用IHD也不会存在明显也不会存在明显的问题的问题,有有RCTs并没有显示出并没有显示出CRRT优于优于IHD Type of therapy Kidney Int 2009,76:42
16、2-427.BMC Nephrol 2010,11:32.Nephrol Dial Transplant 2009,24:512-518.Lancet 2006,368:379-385.对于依赖血管活性药物的对于依赖血管活性药物的AKI患者，患者，CRRT才是最适合的；才是最适合的；依赖血管活性药物的依赖血管活性药物的AKI患者将来接受长期透析的几率患者将来接受长期透析的几率CRRT 间断性间断性治疗；治疗；AKI的急性期推荐应用的急性期推荐应用CRRT，尤其是对于严重血流动力学不稳定、需，尤其是对于严重血流动力学不稳定、需大量清除液体以便于进行更有效药物治疗的患者。大量清除液体以便于进行更有效药物治疗的患者。Crit Care Med 2008,36:610-617.Kidney Int 2009,76:422-427.Nat Rev Nephrol 2010,9:521-529.Clin Pharmacol Ther 2009,86:562-565.目前共识：目前共识：Contents Introduction 1 Type of therapy 2 Timing of CRRT