CRRT的规范化治疗课件.ppt

1、A Pera Global Company PERA ChinaCRRT的规范化治疗 浙江省人民医院孙仁华A Pera Global Company PERA China概述n 连续性肾脏替代治疗（continuous renal replacement therapy，CRRT）是指一组体外血液净化的治疗技术，是所有连续、缓慢清除水分和溶质治疗方式的总称。传统CRRT 技术每天持续治疗24 小时，目前临床上常根据患者病情治疗时间做适当调整。CRRT 的治疗目的已不仅仅局限于替代功能受损的肾脏，近来更扩展到常见危重疾病的急救，成为各种危重病救治中最重要的支持措施之一，与机械通气和全胃肠外营养地

2、位同样重要。血液净化标准操作规程（2010 版）A Pera Global Company PERA ChinaCRRT CRRT is any extracorpreal blood purificattion therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours/day 所谓CRRT也就是指所有每天24小时或接近24小时的缓慢、连续清除水和溶质的治疗方法。

3、A Pera Global Company PERA China历史n 1977年，Kramer等首先提出了连续性动静脉血液滤过(continuous arterio-venous hemofiltration，CAVH)n 1979年，Bambauer-Bishoff提出连续性静脉-静脉血液滤过(CVVH)n 1980年，Paganini提出缓慢连续性超滤(SCUF)n 1984年Geronemus 提出CAVHD，1987-CVVHDn 1985年Ronco首次将CAVHDF应用于治疗l例败血症合并MODS患者n 1992年Grootendorst 提出高容量血液滤过(high volum

4、e hemofiltration，HVHF)n 1998年，Tetra等提出连续性血浆滤过吸附(CPFA)A Pera Global Company PERA China主要技术n 缓慢连续超滤（slow continuous ultrafiltration，SCUF）n 连续性静静脉血液滤过（continuous venovenous hemofiltration，CVVH）n 连续性静静脉血液透析滤过（continuous venovenous hemodiafiltration，CVVHDF）n 连续性静静脉血液透析（continuous venovenous hemodialysis，

5、CVVHD）n 连续性高通量透析（continuous high flux dialysis，CHFD）n 连续性高容量血液滤过（high volume hemofiltration，HVHF）n 连续性血浆滤过吸附（continuous plasmafiltration adsorption，CPFA）血液净化标准操作规程（2010 版）A Pera Global Company PERA ChinaA Pera Global Company PERA ChinaA Pera Global Company PERA ChinaA Pera Global Company PERA ChinaA

6、 Pera Global Company PERA ChinaA Pera Global Company PERA ChinaA Pera Global Company PERA China总 结A Pera Global Company PERA China急性肾损伤n 急性肾损伤(acute kidney injury，AKI)是指发生急性肾功能异常，包括从肾功能微小改变到最终肾衰竭整个过程。A Pera Global Company PERA ChinaRIFLE Criteria for Acute Renal DysfunctionRIFLE Criteria for Acute R

7、enal DysfunctionRiskInjuryFailureLossESRDIncreased creatinine x1.5 or GFR decrease 25%End Stage Renal Disease GFR Criteria*Urine Output CriteriaUO .3ml/kg/hx 24 hr or Anuria x 12 hrsUO .5ml/kg/hx 12 hrUO 50%Increase creatinine x3or GFR dec 75%or creatinine 4mg/dl(Acute rise of 0.5 mg/dl)HighSensitiv

8、ityHighSpecificityPersistent ARF*=complete loss of renal function 4 weeks OliguriaA Pera Global Company PERA China“Acute on Chronic”DiseaseBaseline0.5(44)1.0(88)1.5(133)2.0(177)2.5(221)3.0(265)Risk0.75(66)1.5(133)2.3(200)3.0(265)3.8(332)-Injury1.0(88)2.0(177)3.0(265)-Failure1.5(133)3.0(265)4.0(350)4

9、.0(350)4.0(350)4.0(350)Creatinine is expressed in mg/dL and(mcmol/L).A Pera Global Company PERA ChinaAKIN分层标准 Stage Serum creatinine criteria Urine output Stage Serum creatinine criteria Urine output criteriacriteria 1 Increase in serum creatinine of 1 Increase in serum creatinine of more than or eq

10、ual to 0.3 mg/dl Less than more than or equal to 0.3 mg/dl Less than 0.5 ml/kg per0.5 ml/kg per (26.4 mol/l)or increase to hour for (26.4 mol/l)or increase to hour for more than 6 hoursmore than 6 hours more than or equal to 150%to 200%more than or equal to 150%to 200%(1.5-to 2-fold)from baseline (1

11、.5-to 2-fold)from baseline 2 Increase in serum creatinine to Less than 2 Increase in serum creatinine to Less than 0.5 ml/kg per 0.5 ml/kg per more than200%to 300%hour for more than200%to 300%hour for more than 12hoursmore than 12hours (2-to 3-fold)frombaseline (2-to 3-fold)frombaseline 3 Increase i

12、n serum creatinine to Less than 3 Increase in serum creatinine to Less than 0.3 ml/kg per 0.3 ml/kg per more than300%(3-fold)from hour for more than300%(3-fold)from hour for 24 hours or 24 hours or baseline(or serumcreatinine of anuria baseline(or serumcreatinine of anuria for 12 hoursfor 12 hours m

13、ore than or equato 4.0 mg/dl more than or equato 4.0 mg/dl 354 mol/l with an acute 354 mol/l with an acute increaseof at least 0.5 mg/dl increaseof at least 0.5 mg/dl 44 mol/l)44 mol/l)A Pera Global Company PERA China适应症n 肾脏疾病n 非肾脏疾病血液净化标准操作规程（2010 版）A Pera Global Company PERA China肾脏疾病n 重症急性肾损伤（AKI

14、）伴血流动力学不稳定和需要持续清除过多水或毒性物质，如AKI合并严重电解质紊乱、酸碱代谢失衡、心力衰竭、肺水肿、脑水肿、急性呼吸窘迫综合征（ARDS）、外科术后、严重感染等。n 慢性肾衰竭（CRF）合并急性肺水肿、尿毒症脑病、心力衰竭、血流动力学不稳定等。血液净化标准操作规程（2010 版）A Pera Global Company PERA ChinaAcute renal Acute renal failurefailureAsymptomatic,nonoliguric,adequate nutrition possible(Non)oliguric,haemodynamically s

15、table;life-threathening hyperkalaemia(Non)oliguric,haemodynamically unstableHigh risk of bleedingNo high riskExpectative(Increasing)uraemiaIHD#UnstableCitrate-CRRTCRRTStableAlgorithm for the dialytic treatment of acute renal failure according to circumstancesIHD=intermittent haemodialysis,CRRT=conti

16、nuous IHD=intermittent haemodialysis,CRRT=continuous renal replacement therapy.Delay initiation of renal replacement therapy.Delay initiation of dialytic treatment to maximise the odds of native dialytic treatment to maximise the odds of native renal recovery,#if no citrate-protocol for CRRT,renal r

17、ecovery,#if no citrate-protocol for CRRT,heparin-free IHD may be used as alternative treatmentheparin-free IHD may be used as alternative treatment.A Pera Global Company PERA China非肾脏疾病 非肾脏疾病包括多器官功能障碍综合征（MODS）、脓毒血症或败血症性休克、急性呼吸窘迫综合征（ARDS）、挤压综合征、乳酸酸中毒、急性重症胰腺炎、心肺体外循环手术、慢性心力衰竭、肝性脑病、药物或毒物中毒、严重液体潴留、需要大量补液

18、、电解质和酸碱代谢紊乱、肿瘤溶解综合征、过高热等血液净化标准操作规程（2010 版）A Pera Global Company PERA China禁忌症n CRRT无绝对禁忌证，但存在以下情况时应慎用。n 无法建立合适的血管通路。n 严重的凝血功能障碍。n 严重的活动性出血，特别是颅内出血。血液净化标准操作规程（2010 版）A Pera Global Company PERA ChinaPotential indications for CRRT in the ICUn Nonobstructive oliguria(urine output 200 ml/12 h)or anurian

19、Severe acidaemia(pH 30 mmol/l)n Hyperkalaemia(K+6.5 mmol/l or rapidly rising K+)*n Suspected uraemic organ involvement(pericarditis/encephalopathy/neuropathy/myopathy)Bellomo and Ronco Crit Care 2000,4 4:339345A Pera Global Company PERA ChinaPotential indications for CRRT in the ICUn Progressive sev

20、ere dysnatraemia(Na+160 or 39.5C)n Clinically significant organ oedema(especially lung)n Drug overdose with dialyzable toxinn Coagulopathy requiring large amounts of blood products in patient with or at risk of pulmonary oedema/ARDSAny one of these indications constitutes sufficient grounds for cons

21、idering the initiation of CRRT.Two of the above criteria make CRRT highly desirable.Combined disorders suggest the initiation of CRRT even before some of the above-mentioned limits have been reached.*IHD removes potassium more efficiently than CRRT.However,if CRRT is started early enough,hyperkalaem

22、ia is easily controlled.For example,a fulminant liver failure patient with adult respiratory distress syndrome(ARDS),an international normalized ratio 3 and spontaneous epistaxis.Unless volume is rapidly removed,as fresh frozen plasma is rapidly given,the patient is very likely to develop pulmonary

23、oedema.A Pera Global Company PERA China治疗前患者评估n 选择合适的治疗对象，以保证CRRT 的有效性及安全性。患者是否需要CRRT治疗应由有资质的肾脏专科或ICU 医师决定。肾脏专科或ICU 医师负责患者的筛选、治疗方案的确定等。血液净化标准操作规程（2010 版）A Pera Global Company PERA ChinaCRRT现状调查n Uchino等报道:前瞻性、观察研究结果，2000.9-2001.12，23个国家、54家ICU、1006例患者的CRRT应用情况。n 除1例外均采用V-V通路，CVVH占52.8%，33.1%不抗凝，平均剂量

24、为20.4ml/kg/h，仅11.7%35ml/kg/h。A Pera Global Company PERA ChinaCRRT现状调查n 常用抗凝剂肝素42.9%、枸橼酸9.9%、甲磺酸萘莫司他6.1%、低分子肝素4.4%。n 常见并发症为低血压19%，心律失常4.3%，出血3.3%，其中应用低分子肝素者出血为11.4%n 医院死亡率为63.8%，存活者中有85.5%肾功能恢复A Pera Global Company PERA ChinaAge(years)66(5174)Reasons to start CRRTGender(male)662/1006(65.8%)Oliguria/a

25、nuria 703/1002(70.2%)Premorbid renal function High urea/creatinine 531/1002(53.0%)Normal 590/1006(58.6%)Metabolic acidosis 437/1002(43.6%)Chronic impairment 283/1006(28.1%)Fluid overload 368/1002(36.7%)Unknown 133/1006(13.2%)Hyperkalemia 186/1002(18.6%)SAPS II 48(3962)Immunomodulation 136/1002(13.6%

26、)Predicted mortality(%)41.5(23.071.4)Others 70/1002(7.0%)Hospital to ICU(days)1(07)ICU mortality 555/1003(55.3%)ICU to start(days)1.2(0.44.1)Hospital mortality 641/999(64.2%)Contributing factors to ARF SMR 1.38(1.281.50)Sepsis/septic shock 504/1003(50.2%)Major surgery 377/1003(37.6%)Low cardiac outp

27、ut 262/1003(26.1%)Hypovolemia 201/1003(20.0%)Drug induced 176/1003(17.5%)Hepatorenal syndrome 73/1003(7.3%)Obstructive uropathy 20/1003(2.0%)Others 114/1003(11.4%)Data are presented as median and interquartile ranges(25th75th percentiles)or percentages;SAPS II,Simplified Acute Physiology score;Hospi

28、tal to ICU,duration betweenhospital admission and intensive care unit admission;ICU to start,duration between intensive care unit admission and study inclusion;ARF,acute renal failure;SMR,standardized mortality ratio;ICU,intensive care unit病人基本情况Intensive Care Med(2007)33:15631570A Pera Global Compa

29、ny PERA ChinaCRRT mode AnticoagulationCVVH 531/1006(52.8%)Unfractionated heparin 429/1000(42.9%)CVVHDF 342/1006(34.0%)Sodium citrate 99/1000(9.9%)CVVHD 132/1006(13.1%)Nafamostat mesilate 61/1000(6.1%)CAVHD 1/1006(0.1%)Low-molecular-weight 44/1000(4.4%)Dilution site for replacement fluid heparinPredi

30、lution 509/870(58.5%)Prostacyclin 11/1000(1.1%)Postdilution 361/870(41.5%)Hirudin 9/1000(0.9%)Filter material Heparin-protamine 6/1000(0.6%)Polyacrylonitrile 457/975(46.9%)Others b 3/1000(0.3%)Polysulfone 209/975(21.4%)Combination c 7/1000(0.7%)Polyamide 164/975(16.8%)No anticoagulation 331/1000(33.

31、1%)Cellulose triacetate 89/975(9.1%)Polymethyl-methacrylate 27/975(2.8%)Polyarylether-sulfone 14/975(1.4%)Cellulose diacetate 11/975(1.1%)Others a 4/975(0.4%)a 3 Polyester-polymer-alloy,1 ethylene-vinyl alcohol;b 2 danaparoid,1 warfarin;c 4 heparin-citrate,2 heparin-prostacyclin,1 nafamostat mesilat

32、e-low-molecular-weight heparinCRRT使用情况Intensive Care Med(2007)33:15631570A Pera Global Company PERA ChinaHypotension 188/1000(18.8%)Bleeding 33/997(3.3%)Indwelling vascular catheter sites 13/997(1.3%)Intra-abdominal 3/997(0.3%)Gastrointestinal 3/997(0.3%)Nostril 3/997(0.3%)Sternal wound 3/997(0.3%)O

33、thers a 8/997(0.8%)Arrhythmia 43/1000(4.3%)Atrial fibrillation 24/1000(2.4%)Supraventricular tachycardia 7/1000(0.7%)Cardiac arrest 4/1000(0.4%)Bradycardia 3/1000(0.3%)Ventricular tachycardia 3/1000(0.3%)Atrial flutter 1/1000(0.1%)Ventricular fibrillation 1/1000(0.1%)a Intracranial,lower leg,bone ma

34、rrow aspiration site,oral,and pericardial并发症Intensive Care Med(2007)33:15631570A Pera Global Company PERA ChinaVenkataraman et al,J Crit Care,2002CRRT处方与实际完成的比较A Pera Global Company PERA China何时开始CRRT？n 目前没有统一的标准：“时间”、指标等均不统一。n Getting等报道：早期开始RRT（BUN 42.6mg/dl ）比晚期（BUN 94.5mg/dl）RRT的生存率高（39%-20%）Int

35、ensive Care Med 1999;25:805-813.A Pera Global Company PERA China All Early starters:Late starters:p value (n=100)BUN 60 mg/dl (n=41)(n=59)BUN prior to CRRT(mg/dl)73.2(39.6)42.6(12.9)BUN prior to CRRT(mg/dl)73.2(39.6)42.6(12.9)94.5(28.3)0.000194.5(28.3)0.0001Serum creatinine prior to CRRT(mg/dl):Seru

36、m creatinine prior to CRRT(mg/dl):nonrhabdomyolysis patients(n=89)nonrhabdomyolysis patients(n=89)a a 3.26(1.8)2.69(1.6)3.26(1.8)2.69(1.6)3.59(4.3)0.0253.59(4.3)0.025Serum creatinine prior to CRRT(mg/dl)Serum creatinine prior to CRRT(mg/dl)rhabdomyolysis patients only(n=11)5.94(1.2)5.73(1.06)rhabdom

37、yolysis patients only(n=11)5.94(1.2)5.73(1.06)6.50(1.8)0.3876.50(1.8)0.387Creatinine clearance prior to CRRT Creatinine clearance prior to CRRT(ml/min)(ml/min)b b 15.1(19.3)17.4(26.4)15.1(19.3)17.4(26.4)13.4(11.6)0.33213.4(11.6)0.332Albumin prior to CRRT(g/dl)Albumin prior to CRRT(g/dl)c c 2.61 2.76

38、 2.61 2.76 2.50 0.0492.50 0.049Oliguric on CRRT day 1(%)46.00 56.10 Oliguric on CRRT day 1(%)46.00 56.10 39.00 0.09139.00 0.091Heart rate(beats/min)110.0 116.8 Heart rate(beats/min)110.0 116.8 105.3 0.001105.3 0.001Mean blood pressure(mmHg)88.0 87.8 Mean blood pressure(mmHg)88.0 87.8 88.2 0.91588.2

39、0.915Cardiac index(l/min per mCardiac index(l/min per m2 2)5.07 4.95 )5.07 4.95 5.15 0.5255.15 0.525Stroke volume(ml)91.8 85 Stroke volume(ml)91.8 85 96.6 0.05696.6 0.056Oxygen delivery indexOxygen delivery index(ml O2/min per m(ml O2/min per m2 2)738.8 707.6 )738.8 707.6 760.4 0.239760.4 0.239Patie

40、nts meeting SIRS criteria prior Patients meeting SIRS criteria prior to CRRT(%)91.20 94.60 to CRRT(%)91.20 94.60 88.90 0.34588.90 0.345Hospital day of CRRT initiation 15.8(23.4)10.5(15.3)Hospital day of CRRT initiation 15.8(23.4)10.5(15.3)19.4(27.2)0.000119.4(27.2)24小时，无尿12小时；BUN25-30mmol/lAm J Resp

41、ir Crit Care Med Vol 162.pp 191196,2000Am J Respir Crit Care Med Vol 162.pp 191196,2000A Pera Global Company PERA China治疗模式选择n 临床上应根据病情严重程度以及不同病因采取相应的CRRT模式及设定参数。SCUF和CVVH用于清除过多液体为主的治疗；CVVHD用于高分解代谢需要清除大量小分子溶质的患者；CHFD适用于ARF伴高分解代谢者；CVVHDF有利于清除炎症介质，适用于脓毒症患者；CPFA主要用于去除内毒素及炎症介质。血液净化标准操作规程（2010 版）A Pera G

42、lobal Company PERA China CRRT CRRT 常用治疗模式比较常用治疗模式比较 SCUF SCUF CVVH CVVHD CVVHDFCVVH CVVHD CVVHDF血流量（血流量（ml/minml/min）5050100 50100 50200 200 5050200 50200 50200200透析液流量（透析液流量（ml/minml/min）101020 1020 102020清除率（清除率（L/24hL/24h）121236 36 141436 2036 204040超滤率（超滤率（ml/minml/min）2 25 85 825 25 2 24 84 812

43、12中分子清除力中分子清除力 血滤器血滤器/透析器透析器 高通量高通量 高通量高通量 低通量低通量 高通量高通量置换液置换液 无无 需要需要 无无 需要需要溶质转运方式溶质转运方式 无无 对对流流 弥散弥散 对流弥散对流弥散有效性有效性 用于清除液体用于清除液体 清除较大分清除较大分 清除小分子清除小分子 清除中小分清除中小分 子物质子物质 物质物质 子物质子物质A Pera Global Company PERA ChinaCRRT剂量n 慢性肾衰血透的剂量要求是：kt/V1.2n CRRT的治疗剂量目前尚无统一意见n 高容量血液滤过（HVHF）在严重感染、重症胰腺炎（SIRS）中受推崇。A

44、 Pera Global Company PERA China 41%57%58%A Pera Global Company PERA ChinaA Pera Global Company PERA ChinaSaudan et al,Kidney Int 2006A Pera Global Company PERA ChinaSaudan et al,Kidney Int 2006A Pera Global Company PERA ChinaBouman研究Bouman et al.,Crit Care Med 2002A Pera Global Company PERA ChinaBou

45、man et al.,Crit Care Med 2002A Pera Global Company PERA ChinaBouman et al.,Crit Care Med 2002A Pera Global Company PERA ChinaSchiffl et al,NEJM 2002Schiffl研究：IHD剂量与预后关系A Pera Global Company PERA ChinaSchiffl et al,NEJM 2002Schiffl研究：IHD剂量与预后关系A Pera Global Company PERA ChinaSchiffl et al,NEJM 2002Sc

46、hiffl研究：IHD剂量与预后关系A Pera Global Company PERA ChinaKellum,Nature Clin Pract Nephrol 2007治疗剂量与预后的关系A Pera Global Company PERA ChinaA Pera Global Company PERA ChinaPalevsky et al,NEJM 2008;349(May 20)不同治疗强度间死亡率比较A Pera Global Company PERA ChinaRENAL研究：Randomized Evaluation of Normal versus Augmented Le

47、vel Replacement Therapy StudyA Pera Global Company PERA China KaplanMeier Estimates of the KaplanMeier Estimates of the Probability of Death.Probability of Death.Mortality at 28 days was similar in the higher-intensity and lower-intensity treatment groups(38.5%and 36.9%,respectively),and mortality a

48、t 90 days was the same(44.7%)in both groups.N Engl J Med 2009;361:1627-38.A Pera Global Company PERA China透析剂量n 推荐采用体重标化的超滤率作为剂量单位ml/(kgh)。CVVH 后置换模式超滤率至少达到3545 ml/(hkg)才能获得理想的疗效，尤其是在脓毒症、SIRS、MODS 等以清除炎症介质为主的情况下，更提倡采用高容量模式。血液净化标准操作规程（2010 版）A Pera Global Company PERA China血管通路n 临时导管常用的有颈内、锁骨下及股静脉双腔留

49、置导管，右侧颈内静脉插管为首选，置管时应严格无菌操作。提倡在B 超引导下置管,可提高成功率和安全性。n 带涤纶环长期导管若预计治疗时间超过3 周，使用带涤纶环的长期导管，首选右颈内静脉。血液净化标准操作规程（2010 版）A Pera Global Company PERA China抗凝方案n 普通肝素：采用前稀释的患者，一般首剂量1520mg，追加剂量510mg/h，静脉注射；采用后稀释的患者，一般首剂量2030mg，追加剂量815mg/h，静脉注射；治疗结束前3060 分钟停止追加。抗凝药物的剂量依据患者的凝血状态个体化调整；治疗时间越长，给予的追加剂量应逐渐减少。血液净化标准操作规程（

50、2010 版）A Pera Global Company PERA China抗凝方案n 低分子肝素：首剂量6080IU/kg，推荐在治疗前2030 分钟静脉注射；追加剂量3040IU/kg，每46 小时静脉注射，治疗时间越长，给予的追加剂量应逐渐减少。有条件的单位应监测血浆抗凝血因子Xa 活性，根据测定结果调整剂量。血液净化标准操作规程（2010 版）A Pera Global Company PERA China抗凝方案n 局部枸橼酸抗凝枸橼酸浓度为4%46.7%，以临床常用的一般给予4%枸橼酸钠为例，4%枸橼酸钠180ml/h 滤器前持续注入，控制滤器后的游离钙离子浓度0.250.35m