KDIGO-AKI急性肾损伤诊疗
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KDIGO,2012
Glycemic control and nutritional support
• In critically ill patients, we suggest insulin therapy targeting plasma glucose 110–149 mg/dl(6.1–8.3 mmol/l). ( 2C)
• We suggest achieving a total energy intake of 20–30 kcal/kg/d in patients with any stage of AKI. (2C)
• We suggest to avoid restriction of protein intake with the aim of preventing or delaying initiation of RRT. ( 2D)
KDIGO,2012
指南推荐强度
ห้องสมุดไป่ตู้
Quality of evidence
A－High
B－ Moderate
C－Low
Strength of recommendatio
n
Level1－strong
Level2－weak or discretionary
D－Very low
KDIGO,2012
指南推荐强度
• We suggest administering 0.8–1.0 g/kg/d of protein in non catabolic AKI patients without need for dialysis ( 2D), 1.0–1.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients. ( 2D)
KDIGO,2012
Diuretics against
Mehta RL, Pascual MT, Soroko S et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002; 288: 2547-2553 Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333 (7565): 420-425
KDIGO,2012
The use of diuretics in AKI
• At present, the current evidence does not suggest that furosemide can reduce mortality in patients with AKI.
• Mannitol is not scientifically justified in the prevention of AKI.
KDIGO,2012
Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides
• We recommend not using low-dose dopamine to prevent or treat AKI. （1A）
• We suggest that, in patients with normal kidney function in steady state, aminoglycosides are administered as a single dose daily rather than multiple-dose daily treatment regimens. (2B)
• We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for AKI. ( 1C)
• We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting (2C) or in patients with septic shock (2C)
• We suggest providing nutrition preferentially via the enteral route in patients with AKI. (2C）
KDIGO,2012
Growth factor intervention
• We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI. （1B）
Chapter 2.2: Risk assessment
KDIGO,2012
Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.
KDIGO,2012
AKI/CKD/AKD
KDIGO,2012
Guideline 3：Prevention and
Treatment of AKI HIGH RISK
KDIGO,2012
Stage-based management of AKI
Chapter 2.3:Evaluation and general management of patients with and at risk for AKI
• We suggest using topical or local applications of aminoglycosides (e.g., respiratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. ( 2B)
KDIGO,2012
Guidline 3
• In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI. (2B)
human IGF-1：重组人胰岛素样生长因子1
KDIGO,2012
Prevention of aminoglycoside- and amphotericin-related AKI
• We suggest not using aminoglycosides for the treat-ment of infections unless no suitable, less nephro-toxic, therapeutic alternatives are available. (2A)
• Urine volume 0.5ml/kg/h for 6 hours.
KDIGO,2012
AKI分期标准
指南推荐血清肌酐和尿量仍然作为AKI最好的标志物(1B)
KDIGO,2012
Guideline ：
KDIGO,2012
Chapter 2.2: Risk assessment
KDIGO,2012
KDIGO：Kidney Disease Improving Global Outcomes
KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012
KDIGO,2012
About AKI guideline
• ADQI：2002, RIFLE • AKIN：2005, modified definition and staging system • KDIGO: 2011, First clinical guideline for AKI
• We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A)
• We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used for more than 48 hours. (2C)
– Waiting for published in this summer • AKI guideline for AKI :2011
– UK Renal Association Final Version 08.03.11 • AKI guidline—KDIGO 2012
– KDIGO Clinical Practice Guideline for Acute Kidney Injury
• We suggest not using fenoldopam（非诺多巴） to prevent or treat AKI. ( 2C)
• We suggest not using atrial natriuretic peptide (ANP) to prevent (2C) or treat ( 2B) AKI
KDIGO,2012
Chapter 3.4: The use of diuretics in AKI
• We recommend not using diuretics to prevent AKI. (1B)
• We suggest not using diuretics to treat AKI, exceptin the management of volume overload. ( 2C)
KDIGO,2012
AKI is defined as any of the following (Not Graded):
• Increase in SCr by 0.3mg/dl (X26.5 mol/l) within 48 hours; or Increase in SCr to1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or
Glycemic control and nutritional support
• In critically ill patients, we suggest insulin therapy targeting plasma glucose 110–149 mg/dl(6.1–8.3 mmol/l). ( 2C)
• We suggest achieving a total energy intake of 20–30 kcal/kg/d in patients with any stage of AKI. (2C)
• We suggest to avoid restriction of protein intake with the aim of preventing or delaying initiation of RRT. ( 2D)
KDIGO,2012
指南推荐强度
ห้องสมุดไป่ตู้
Quality of evidence
A－High
B－ Moderate
C－Low
Strength of recommendatio
n
Level1－strong
Level2－weak or discretionary
D－Very low
KDIGO,2012
指南推荐强度
• We suggest administering 0.8–1.0 g/kg/d of protein in non catabolic AKI patients without need for dialysis ( 2D), 1.0–1.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients. ( 2D)
KDIGO,2012
Diuretics against
Mehta RL, Pascual MT, Soroko S et al. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002; 288: 2547-2553 Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 2006; 333 (7565): 420-425
KDIGO,2012
The use of diuretics in AKI
• At present, the current evidence does not suggest that furosemide can reduce mortality in patients with AKI.
• Mannitol is not scientifically justified in the prevention of AKI.
KDIGO,2012
Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides
• We recommend not using low-dose dopamine to prevent or treat AKI. （1A）
• We suggest that, in patients with normal kidney function in steady state, aminoglycosides are administered as a single dose daily rather than multiple-dose daily treatment regimens. (2B)
• We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for AKI. ( 1C)
• We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk patients in the perioperative setting (2C) or in patients with septic shock (2C)
• We suggest providing nutrition preferentially via the enteral route in patients with AKI. (2C）
KDIGO,2012
Growth factor intervention
• We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI. （1B）
Chapter 2.2: Risk assessment
KDIGO,2012
Overview of AKI, CKD, and AKD. Overlapping ovals show the relationships among AKI, AKD, and CKD. AKI is a subset of AKD. Both AKI and AKD without AKI can be superimposed upon CKD. Individuals without AKI, AKD, or CKD have no known kidney disease (NKD), not shown here. AKD, acute kidney diseases and disorders; AKI, acute kidney injury; CKD, chronic kidney disease.
KDIGO,2012
AKI/CKD/AKD
KDIGO,2012
Guideline 3：Prevention and
Treatment of AKI HIGH RISK
KDIGO,2012
Stage-based management of AKI
Chapter 2.3:Evaluation and general management of patients with and at risk for AKI
• We suggest using topical or local applications of aminoglycosides (e.g., respiratory aerosols, instilled antibiotic beads), rather than i.v. application, when feasible and suitable. ( 2B)
KDIGO,2012
Guidline 3
• In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin orstarches) as initial management for expansion of intravascular volume in patients at risk for AKI or with AKI. (2B)
human IGF-1：重组人胰岛素样生长因子1
KDIGO,2012
Prevention of aminoglycoside- and amphotericin-related AKI
• We suggest not using aminoglycosides for the treat-ment of infections unless no suitable, less nephro-toxic, therapeutic alternatives are available. (2A)
• Urine volume 0.5ml/kg/h for 6 hours.
KDIGO,2012
AKI分期标准
指南推荐血清肌酐和尿量仍然作为AKI最好的标志物(1B)
KDIGO,2012
Guideline ：
KDIGO,2012
Chapter 2.2: Risk assessment
KDIGO,2012
KDIGO：Kidney Disease Improving Global Outcomes
KDIGO Clinical Practice Guideline for Acute Kidney Injury,2012
KDIGO,2012
About AKI guideline
• ADQI：2002, RIFLE • AKIN：2005, modified definition and staging system • KDIGO: 2011, First clinical guideline for AKI
• We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours. (1A)
• We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used for more than 48 hours. (2C)
– Waiting for published in this summer • AKI guideline for AKI :2011
– UK Renal Association Final Version 08.03.11 • AKI guidline—KDIGO 2012
– KDIGO Clinical Practice Guideline for Acute Kidney Injury
• We suggest not using fenoldopam（非诺多巴） to prevent or treat AKI. ( 2C)
• We suggest not using atrial natriuretic peptide (ANP) to prevent (2C) or treat ( 2B) AKI
KDIGO,2012
Chapter 3.4: The use of diuretics in AKI
• We recommend not using diuretics to prevent AKI. (1B)
• We suggest not using diuretics to treat AKI, exceptin the management of volume overload. ( 2C)
KDIGO,2012
AKI is defined as any of the following (Not Graded):
• Increase in SCr by 0.3mg/dl (X26.5 mol/l) within 48 hours; or Increase in SCr to1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; or