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1、.,.WaikarSS,etal.JAmSocNephrol.20061988-2002556338159876810000040,4%20,3%41,3%28,1%P0,001 q4016q1141q34824,7%OR=1,59AdeMendoncaetal.IntensiveCareMed.2000MetnitzPGetal.CritCareMed.2002q 30q 17126q 839(4,9%)q 54232000-2001.q 29269q 17385,7%q 12604,2%UchinoSetal.JAMA.2005-51,7%-60,3%BESTKidneyStudy:q15
2、897q80.()47 1956 2003.,.YmpaYPetal.AmJMed.2005?/AdeMendoncaetal.2000.308/(3,5mg/dl)1,4mg/dl(123/)UchinoSetal.2005.30/(84mg/dl)200/12.Herrera-GutierrezME2006.2mg/dl(176/)400/24.RIFLE n=1766R n=670I n=1436F n=1511 n=5383 1(0,1%)0(0%)4(0,3%)214(14,2%)219(4,1%)3(2-4)3(2-6)5(3-10)9(4-21)4(2-9)975,5%598,8
3、%16311,4%39826,3%71713,3%HosteE,etal.CriticalCare2006201262000-2002.UchinoS,etal.CritCareMed.2006 RIFLE 419721989-1999.22OstermannM,CritCareMed.2007AKI=35,8%64,2%17,2%11%7,6%AKIN-.(48.):0,3mg/dl(26,4/)50%.0,5/6MehtaRL,etalCritCare.2007 LassniggAetal.JAmSocNephrol2004q 4118.q 48.30-.Ccr0,3mg/dl(26/)C
4、cr0,3mg/dl(26/)R(95%)RRSCr 0.3mg/dl 6.9(5.2-9.0)6.6(5.0-8.6)4.1(3.1-5.5)SCr 0.5 mg/dl 11.1(8.7-14.2)10.6(8.3-13.6)6.5(5.0-8.5)SCr 1.0 mg/dl 19.9(15.1-26.1)19.0(14.4-25.0)9.7(7.1-13.2)SCr 2.0 mg/dl 36.4(24.3-54.6)37.7(25.0-56.9)16.4(10.3-26.0)SCr 25%4.0(3.0-5.2)3.9(3.0-5.2)2.0(1.2-3.9)SCr 50%5.9(4.6-
5、7.5)5.8(4.6-7.5)4.4(3.4-5.7)SCr 100%8.9(6.9-11.4)9.2(7.1-11.8)6.5(4.9-8.6)ChertowGM,etal.JAmSocNephrol.200519982-RIFLE(AKIN)RIFLE(AKIN)().(23).(1).RIFLEAKIN.ARFARFAKIAKI5,7-16,6%.:42,3-60,3%10,8-35,8%.:RIFLE R 8,8-20,9%RIFLE I 11,4-45,6%RIFLE F 26,3-56,8%,.-()Kellum JA et al.ADQI 4.2005 ./RIFLE,AKIN
6、(,)(,)(),(,)DrumlW.IntensiveCareMed.2004.MehtaRL.2006.Na,NaCl.,.Gibney N,et al ADQI 4,2005 N-D E NGibney,etalADQI4,2005,MAP,-FriedrichJ.O.,etal.AnnInternMed.2005-6319802004.3359.OR=0,96(0,78-1,19)OR=0,93(0,76-1,15),?NO?-1()?.?(,)()RIFLE(AKIN)?,?1989-1997100-:,60mg/dl(94,5mg/dl)19,4P=0,0001 0,0001Get
7、tingsLGetal.IntensiveCareMed.1999P=0,041?28-.(35.)48,2(42,3-58,7)/74,3%P=0,8 4,3(1,4-7,8).P=0,25(35.)20,1(17,5-22,0)/68,8%3,2(2,4-5,4).(36.)19,0(16,6-21,1)/75,0%5,6(3,1-8,5).-7.42.BoumanCS,etal.CritCareMed.2002?ElahiMM,etal.EurJCardiothoracSurg.200464().(%)30/2,55+2,2 4,57+11,4 12(43%)p=0,001 ns 0,0
8、5?DemirkiliUetal.JCardSurg.200461(n=34)5mg/dl(440/)5,5/()()0,9+0,3 12,0+3,4 2,6+1,7 7,9+1,3p=0,0001 0,0001?37(21/16.)51,4+11,61.1000/96.n=103.4000/96.n=9:88,9%:73,7%p0.01JiangHetal.WorldJGastroenterol2005?ProgramtoImproveCareinAcuteRenalDisease(PICARD).243(n=122)76mg/dlLiuK,etal.ClinJAmSocNephrol200
9、6OR=1.85(1.16-2.96).?IHD,IHDF CVVHD,CVVH,CVVHDF SLED16/4,5/CRRT IHD?CRRT IHD(,).on-line.-FliserD.NatClinPractNephrol.2006?Acute Dialysis Quality Initiative2ndInternationalConsensusConferenceMehtaRL,etal.Arandomizedclinicaltrialofcontinuousversusintermittentdialysisforacuterenalfailure.KidneyInt.2001
10、V.60P.1154-1163CRRT IHD?CVVHDF IHD=/15918 231560,0001 20,56,2 3,00,4 0,0001/304 198390,0001/25,95.9 24,811.3 0,34IHDCVVHDFUehlingerDetal.NDT2005,125SAPSII-55-55%-95%=77,6%IHD(n=55)CVVHDF(n=70)2000/CRRT IHD?CVVHDF IHD=MAP65mmHg n=15(21%)n=8(15%)0,36:%n=31(44%)n=15(27%)0,06:%n=38(54%)n=28(51%)0,72:%n=
11、31(44%)n=19(35%)0,36UehlingerDetal.NDT2005CRRT IHD?:CVVHDF34%IHD38%=0,71:CVVHDF47%IHD51%=0,72:CVVHDF-6(1-49)IHD-7(1-50)=0,99:CVVHDF-20,5(6-71)IHD30-(2-89)=0,25,.UehlingerD.etal.NDT2005CRRT IHD?:,(21)1999-2003.360:(36/SCr310/),LOD5:IHDCVVHDFAN69.:CVVHDF=32,6%IHD=31,5%Hemodiafe.22462,2%66+13SAPS265+14
12、89%97%IHDn=126CVVHDFn=98:IHD=28,6%CVVHDF=23,5%p=0,23,.Vinsonneau,etal.Lancet2006 7:CVVHDF=65%IHD=64%=0,65OR=0,98(95%0,94-1,14)CRRT IHD?BarrioV,etal.Nefrologia.2007-308CRRTIHD:RR=1,1(95%0,99-1,23)n RR=0,91(95%0,56-1,49)PannuN,etal.JAMA2008 CRRT IHD?22000-2001.16184CRRT77IHDRaufAA,etal.IntensiveCareMe
13、d.2008?Ronco,BESTKidneyStudy2000LedeboI,DialysisOpions2005MontiG,etal.TheDOseREsponseMulticentreInternationalCollaborativeInitiative(DO-RE-MI)2006OverbergerP,etal.ASurveyofPractitionerPrescribingPractices2007?,KellumJANatClinPractNephrol2007()?SchifflH,etal.NIJM2002 IHDn=74IHDn=72P=()5913 6114 nsAPA
14、CHE3()897 859(%)41%32%(mg/d)l 4,61,0 4,91,4HD()3,30,4 3,40,5(Kt/V)0,920.16 0,940.11n(%)22(28%)37(46%)0,01()92 166 0,001:,2000-2003.206:1-2,5/1-2,5/1-1,5/?SaudanP,etal.KidneyInt.20062839%59%(=0,03)9034%59%(=0,0005)71%78%(=0,62)PalevskyMetal.NEnglJMed2008:2mg/dL424SOFA()2SOFACV2IHD 3/IHD 6/SOFACV2 20/
15、SLED 3/35/SLED 6/(n=563)(n=561)()59,615,3 59,715,2/(%)72,6/27,4 68,6/31,4(%)80,5 80,7(%)63,6 62,4APACHEII()26,67,2 26,17,5SOFA()14,73,7 14,43,7SOFACV0-2 45,3%45,3%SOFACV3-4 54,7%54,7%(mg/dl)65,930,2 66,735,2(%)78%78,1%Acute Renal Failure Trial Network studyPalevskyMetal.NEnglJMed2008 ATN-PalevskyMetal.NEnglJMed200860-,RIFLE(AKI).-.!