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1、持续肾脏替代治疗的局部枸橼酸抗凝北京协和医院杜斌ICU中的急性肾脏功能衰竭*:BESTKidney患病率1738/29269(5.7%,95%CI5.5–6.0%)危险因素感染性休克(47.5%,95%CI45.2–49.5%)住院病死率60.3%(95%CI58.0–62.6%)*少尿(<200ml/12hr)和(或)明显的氮质血症(BUN>84mg/dL)UchinoS,KellumJA,BellomoR,etal.Acuterenalfailureincriticallyillpatients:amultinational,multicenterstudy.JAMA2005
2、;294:813-818急性肾功能衰竭的定义:RIFLE标准GFR标准UO标准Risk肌酐增加x1.5或GFR降低>25%UO<0.5ml/kg/hrx6hrInjury肌酐增加x2或GFR降低>50%UO<0.5ml/kg/hrx12hrFailure肌酐增加x3或GFR降低>75%UO<0.3ml/kg/hrx24hr或无尿x12hrLoss持续ARF=肾脏功能完全丧失>4周ESRD终末期肾病>3月BellomoR,RoncoC,KellumJA,etal.Acuterenalfailure:definition,outcomemeasures,animalmodels,fl
3、uidtherapyandinformationtechnologyneeds:theSecondInternationalConsensusConferenceoftheAcuteDialysisQualityInitiative(ADQI)Group.CritCare2004;8:R204-R212ICU的急性肾脏损伤(AKI)OstermannM,ChangRWS.AcutekidneyinjuryintheintensivecareunitaccordingtoRIFLE.CritCareMed2007;35:1837-184335.8%急性肾功能衰竭的治疗(n=646)
4、Perez-ValdiviesoJR,Bes-RastrolloM,MonederoP,etal.Prognosisandserumcreatininelevelsinacuterenalfailureatthetimeofnephrologyconsultation:anobservationalcohortstudy.BMCNephrology2007;8:14-22持续肾脏替代治疗管路寿命满足治疗要求降低治疗费用减少重新安装管路的护理时间18–30hrHoltAW,BiererP,GloverP,PlummerJL,BerstenAD.Conventionalcoagula
5、tionandthromboelastographparametersandlongevityofcontinuousrenalreplacementcircuits.IntensiveCareMed2002;28:1649-55.StefanidisI,HagelJ,FrankD,MaurinN.Hemostaticalterationsduringcontinuousvenovenoushemofiltrationinacuterenalfailure.ClinNephrol1996;46(3):199-205.KoxWJ,RohrU,WaurerH.Practicalasp
6、ectsofrenalreplacementtherapy.IntJArtifOrgans1996;19:100-5.TanHK,BaldwinI,BellomoR.Continuousveno-venoushaemofiltrationwithoutanticoagulationinhigh-riskpatients.IntensiveCareMed2000;26:1652-7.持续肾脏替代治疗的影响因素血管通路位置中心静脉导管:口径,管腔设计血流可靠性血滤管路设计透析膜的生物相容性护理人员的培训及专业技能抗凝效果持续肾脏替代的抗凝血滤滤器与管路的抗凝作用全身抗凝有害作用持续肾
7、脏替代的抗凝选择基础疾病现有抗凝措施临床经验国内文献报告的抗凝方法抗凝方法病例数(%)单药抗凝普通肝素844(37.9)低分子肝素686(30.8)枸橼酸26(1.2)联合抗凝普通肝素+低分子肝素483(21.7)普通肝素+枸橼酸52(2.3)无抗凝137(6.1)CRRT时的肝素抗凝出血危险负荷剂量IU/kg维持剂量IU/kg/hrAPTTsecACTsec无危险性5010–2060<250危险较小15–255–1045160–180危险较大102.5–530120肝素抗凝的优
