腎替代性治療RenalReplacementTherapy

(RRT)

腎替代性治療

腎替代性治療AcuteKidneyInjury(AKI)

[AcuteRenalFailureARF]腎替代性治療腎替代性治療PreventionIdentificationofhigh-riskpatientsforpharmacologicagents-inducednephrotoxicityiodinatedradiocontrastmedium,NSAIDsAggressivesurveillancefornephrotoxin-inducedrenaldysfunctioncisplatin,amphotericinB,aminoglycosideUseofvolumeexpansioninselectedclinicalsettingsHyperpigmenturia:hemoglobinuria,myoglobinuriaCrystaluria:uricacid,acyclovir,methotrexate,sulfonamidesMinimalizationofcathetersusetoavoidnosocomialsepsis腎替代性治療EtiologyTreatment

CorrectpostrenalfactorCorrectprerenalfactorTreatunderlyingsepsisStopnephrotoxicdrugs腎替代性治療Evaluationofintravascularvolume腎替代性治療GuideofVolumeExpansionCVP8-14cmH2OPAWP12-16mmHgUrineoutput0.5-1.0ml/kg/hourWeighingthepatientdailyInsensiblewaterlossfromtheskinandrespiratorytract(500ml/day)腎替代性治療ConservativeMeasurementFluidbalanceCarefulmonitoringofI/OandbodyweightFluidrestriction(usuallylessthan1L/dayinoliguricARF)Totalintake<urineoutput+extrarenallossesElectrolytesandacid-basebalancehyperkalemiahyponatremiaKeepserumbicarbonate>15hyperphosphatemiaTreathypocalcemiaonlyifsymptomatic腎替代性治療Uremia-nutritionRestrictionproteinbutmaintaincaloricintakeCarbohydrate≥100gm/daytominimizeketosisandproteincatabolismDrugReviewallmedication,Stopmagnesium-containingmedicationAdjusteddosageforrenalfailure,ReadjustwithimprovementofGFRConservativeMeasurement腎替代性治療DietarymodificationTotalcaloricintake–35~50kcal/kg/daytoavoidcatabolismSaltrestriction–2~4g/dayPotassiumintake–40meq/dayPhosphorusintake–800mg/day腎替代性治療RenalReplacementTherapy腎替代性治療IndicationsforRenalReplacementTherapyProphylacticdialysis:BUN80-100mg/dl,creatinine8-10mg/dlVolumeoverloadingwithrefractorytodiureticsPulmonaryedemaHyperkalemia>6.5mEq/lSeveremetabolicacidosis<7.1UremicpericarditisUremicencephalopathy:coma,seizureAcuteuricacidnephropathy腎替代性治療MethodsforRenalReplacementTherapyIntermittenthemodialysisPeritonealdialysisContinuousrenalreplacementtherapy:CAVH/CAVHD/CVVHDF,CVVH/CVVHD/CVVHDF腎替代性治療MechanismsDiffusion:movementofsolutetowardsthesameconcentrationoneachsideofmembrane.Convection:soluteis‘carried’togetherwithsolventacrossthemembranebyfiltration.Ultrafiltration:plasmawaterandcrystalloidsseparatedfromthewholebloodacrossasemipermeablemembraneinresponsetoaTMP.Osmosis:operatesinperitonealdialysis.(glucoseistheosmoticagent)腎替代性治療Dialysis腎替代性治療Ultrafiltration

腎替代性治療IntermittenthemodialysisinARFandcriticallyillpatients腎替代性治療PeritonealdialysisInfusionofpyogen-freesolutionintotheperitonealcavity,drainedinsubsequentcycles.Mechanism:diffusion,convection,andosmoticultrafilationIndications:patientsatriskofbleedingfluidoverloadinCVinstability腎替代性治療Peritonealdialysis腎替代性治療腎替代性治療Continuousrenalreplacementtherapy(CRRT)連續(xù)性腎替代性治療

腎替代性治療急性腎衰竭仍是重癥病患常見併發(fā)癥之一，且死亡率極高(>50%)重癥病患常合併有低血壓，血行動力不穩(wěn)，多重器官衰竭；且常需大量輸液(升壓劑,輸血)合併急性腎衰竭需透析時常合併

(1)血行動力不穩(wěn)定

(2)大量輸液無法依需要給予（如TPN)CRRT提供另類腎替代療法的選擇，並可避免傳統(tǒng)間歇性血液透析(intermittenthemodialysis,IHD)執(zhí)行上的缺點CRRT腎替代性治療CRRT種類連續(xù)性動脈靜脈血液過濾術(shù)(CAVH)Continuousarteriovenoushemofiltraton連續(xù)性靜脈靜脈血液過濾術(shù)（CVVH）Continuousvenous-venoushemodialysis連續(xù)性動脈靜脈血液透析術(shù)（CAVHD）連續(xù)性靜脈靜脈血液透析術(shù)（CVVHD）Continuousvenous-venoushemodialysis連續(xù)性動脈靜脈血液透析過濾術(shù)（CAVHDF）連續(xù)性靜脈靜脈血液透析過濾術(shù)（CVVHDF）Continuousvenous-venoushemodiafiltration腎替代性治療腎替代性治療CAVH腎替代性治療CVVH腎替代性治療腎替代性治療腎替代性治療腎替代性治療腎替代性治療腎替代性治療CRRT的適應癥A.Renalindications -hemodynamicinstability -multipleorgansdysfunctionsyndromeaccompaniedbyrenalfailure -acuterenalfailurewithcerebraledemaB.Non-Renalindications-possibleremovalofsubstancesactiveas‘mediators’腎替代性治療適應癥(1)急慢性腎衰竭及血壓不穩(wěn)定休克患者之併發(fā)癥。

(2)呼吸窘迫癥候群。(3)多重器官衰竭。(4)鬱血性心衰竭、或肝衰竭。(5)敗血性休克。(6)燙傷併血壓不穩(wěn)。(7)器官移植後急性腎衰竭。(8)毒藥物中毒。腎替代性治療CRRT的優(yōu)點Avoidanceofelectrolyte,waterandureafluctuationGradualurearemovalHemodynamicstabilitywithslowultrafiltrationOptimalfluidbalanceandunlimitedalimentationEliminationofsepticmediatorsLowerintracranialpressureImprovedoutcome腎替代性治療CRRT的缺點出血危險性（常需使用抗凝劑）limitedmobilityslowersoluteandfluidremoval腎替代性治療MMHCRRTOrder

Modality:(CVVH,CVVHD,CVVHDF)

AKpriming:N/S500ccx2BTaaheparin0.5cc

Anticoagulation:PrepareHeparin12,500U+N/S500ccIVD10cc/hrwithpumptokeepaPPT1.5-2

andadjustasfollowed

aPTT hold dose(ml/h)

<1.5

- +2

1.5-2.0x - Notchange

2.0-2.5x 30mins -2

>2.5x 60mins -4Ifnon-heparin,N/S(250)ccQ30minstorinsetheAK

腎替代性治療

Predilution:run999cc/hralternatelyasfollowedviaarteryend

1stbottleN/S500cc+Sinca1amp

2ndbottleN/S500cc+10%MgSO44cc

3rdbottleN/S500cc

4thbottleD5W500cc+NaHCO35ampDialysate:1.5%PDsolutionrun999cc/hrWarmPredilution&Dialysateto37.0℃

RecordI/O&BPQ1H

UFtarget:I-O=(-40)cc/hr

Monitor:BUN,Cr,Na,K,ClQ12Hx1dayandthenQDCa,PQD;MgQW1,4aPTTQ12HKClsupplement:腎替代性治療腎替代性治療MMH配方

(Predilution)Predilutionrun500cc/hralternatelyasfollowedviaarteryend:1stbottleN/S500cc+Sinca1amp2ndbottleN/S500cc+10%MgSO44cc3rdbottleN/S500cc4thbottleD/W500cc+NaHCO35amp電解質(zhì)

mEg/LNa+Mg2+Ca2+Cl-HCO3-K+MMH配方148.401.512.12109.0739.420腎替代性治療腎替代性治療Dialy