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1、CRRT的规范化治疗 概述 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位同样重要。血液净化标准操作规程（2010 版）CRRT CRRT is any extracorpreal blood purificattion
2、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。历史 1977年，Kramer等首先提出了连续性动静脉血液滤过(continuous arterio-venous hemofiltration，CAVH)1979年，Bambauer-Bishoff提出连续性静脉
3、-静脉血液滤过(CVVH)1980年，Paganini提出缓慢连续性超滤(SCUF)1984年Geronemus 提出CAVHD，1987-CVVHD 1985年Ronco首次将CAVHDF应用于治疗l例败血症合并MODS患者 1992年Grootendorst 提出高容量血液滤过(high volume hemofiltration，HVHF)1998年，Tetra等提出连续性血浆滤过吸附(CPFA)主要技术 缓慢连续超滤（slow continuous ultrafiltration，SCUF）连续性静静脉血液滤过（continuous venovenous hemofiltration，
4、CVVH）连续性静静脉血液透析滤过（continuous venovenous hemodiafiltration，CVVHDF）连续性静静脉血液透析（continuous venovenous hemodialysis，CVVHD）连续性高通量透析（continuous high flux dialysis，CHFD）连续性高容量血液滤过（high volume hemofiltration，HVHF）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）总 结急性肾损伤 急性肾损伤(acute kid
5、ney 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。RIFLE Criteria for Acute Renal 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
6、 x3or GFR dec 75%or creatinine 4mg/dl(Acute rise of 0.5 mg/dl)HighSensitivityHighSpecificityPersistent ARF*=complete loss of renal function 4 weeks Oliguria“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
7、)3.0(265)-Failure1.5(133)3.0(265)4.0(350)4.0(350)4.0(350)4.0(350)Creatinine is expressed in mg/dL and(mcmol/L).AKIN分层标准 Stage Serum creatinine criteria Urine output criteria 1 Increase in serum creatinine of more than or equal to 0.3 mg/dl Less than 0.5 ml/kg per (26.4 mol/l)or increase to hour for
8、more than 6 hours more than or equal to 150%to 200%(1.5-to 2-fold)from baseline 2 Increase in serum creatinine to Less than 0.5 ml/kg per more than200%to 300%hour for more than 12hours (2-to 3-fold)frombaseline 3 Increase in serum creatinine to Less than 0.3 ml/kg per more than300%(3-fold)from hour
9、for 24 hours or baseline(or serumcreatinine of anuria for 12 hours more than or equato 4.0 mg/dl 354 mol/l with an acute increaseof at least 0.5 mg/dl 44 mol/l)适应症 肾脏疾病 非肾脏疾病血液净化标准操作规程（2010 版）肾脏疾病 重症急性肾损伤（AKI）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。慢性肾衰竭
10、（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）Acute renal failureAsymptomatic,nonoliguric,adequate nutrition possible(Non)oliguric,haemodynamically stable;life-threathening hyperkalaemia(Non)oliguric,haemodynamically unstableHigh risk of bleedingNo high riskExpectative(Increasing)uraemiaIHD#Un
11、stableCitrate-CRRTCRRTStableAlgorithm for the dialytic treatment of acute renal failure according to circumstancesIHD=intermittent haemodialysis,CRRT=continuous renal replacement therapy.Delay initiation of dialytic treatment to maximise the odds of native renal recovery,#if no citrate-protocol for
12、CRRT,heparin-free IHD may be used as alternative treatment.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、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）禁忌症 CRRT无绝对禁忌证，但存在以下情况时应慎用。无法建立合适的血管通路。严重的凝血功能障碍。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（20
13、10 版）Potential indications for CRRT in the ICU Nonobstructive oliguria(urine output 200 ml/12 h)or anuria Severe acidaemia(pH 30 mmol/l)Hyperkalaemia(K+6.5 mmol/l or rapidly rising K+)*Suspected uraemic organ involvement(pericarditis/encephalopathy/neuropathy/myopathy)Bellomo and Ronco Crit Care 200
14、0,4:339345Potential indications for CRRT in the ICU Progressive severe dysnatraemia(Na+160 or 39.5C)Clinically significant organ oedema(especially lung)Drug overdose with dialyzable toxin Coagulopathy requiring large amounts of blood products in patient with or at risk of pulmonary oedema/ARDSAny on
15、e of these indications constitutes sufficient grounds for considering 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
16、 than CRRT.However,if CRRT is started early enough,hyperkalaemia 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 oedema.治疗前患者评估 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）CRRT现状调查 Uchino等报道
