лечение острого повреждения почек

.
.
1
Kellum JA, Leblanc M, Gibney RT et al. Primary prevention of acute renal
failure in the critically ill. Curr Opin Crit Care. 2005;11(6):537-41
)
:
III-IV
2
1
II.
3
III.
4
2
1
2
3
Cr
Rg(
)
.
5
Mehran R, Aymong ED, Nikolsky E et al.A simple risk score for
prediction of contrast-induced nephropathy after percutaneous
coronary intervention: development and initial validation.J Am Coll
Cardiol. 2004 Oct 6;44(7):1393-9.
6
3
.
.
183
183
,
Cr 25%
34% vs 7%
—
Cr>25%
.5
7.1% /1.1%;
35.7%
—
Cr 25%
.2
14.9% /4.9%;
22.6%
37.7% /19.4%
1-
27.5%/1.0%
54.5% /6.4%
1-
>0.5 mg/dl
..48
22.0% /1.4%
12.1% /3.7% (1 );
44.6%/14.5% (5 )
Cr 25%
. 48
6.3%/0.8%
(+) ;
2.5%/0.1% (
22.6% /6.9%
(CKD(+); 8.0%/2.7
% (CKD( ); 1-
l
Levy et al., 1996
1826
/2251;
McCullough, 1997
439
Gruberg et al., 2000
7741;
Gruberg et al., 2001
254
/6890
;
Rihal et al., 2002
5250
1980
(+),
);
Dangas et al., 2005
)
7
1.
:
=
<1
,
;
3% ; >1
25%
Nyman U et al. Contrast medium dose-to-GFR ratio: a measure of systemic
exposure to predict contrast-induced nephropathy after percutaneous coronary
intervention. Acta Radiol 2008; 49: 658–667
2.
(500-700
3.
)
0.9%
6-12
12-24
.
8
4
–
:
•OH (
H2O2
(•O2
.
),
.
3
1
1
6
9
NTrivedi H, Daram S, Szabo A, et al. High-dose
N-acetylcysteine for the prevention of contrast-induced nephropathy. Am J
Med 2009; 122:874.e9–874.15:
980
48
300
24
–
1330
48
Awal A et al. Effect of hydration with or without nacetylcysteine on contrast induced nephropathy in patients undergoing
coronary angiography and percutaneous coronary intervention.Mymensingh
Med J. 2011 Apr;20(2):264-9.:
0,9% 1
12
12
N-
600
×2
10
5
•
•
Na
•
-
•
PgE2
)
•
10%,
100%
11
– 75% (Bagshaw SM, Delaney
A, Jones D et al. Diuretics in the management of acute
kidney injury: a multinational survey.Contrib Nephrol.
2007;156:236–249).
100
(30
)
)=
3
II
(1-2
)
12
6
•
•
•
•
•
(
(
)=80-85%
(
(
)=97-99%
) =90-95%
)=90-97%
)=90-98%
•
•
•
•
(
)=90-95%
)=95-98%
(
(
) 80-95%
)=80-95%
13
1.
2.
Na
3.
4.
5.
14
7
Kwok M Ho BMJ 2006;
333:420
250
1996-2006 9
849
1,11 (0,921,33), =0,28
0,99 (0,8-1,22) =0,91
15
Pg
16
8
17
PER OS
18
9
– per os
2,5
.
(10-12
30-40
19
1-2
75%
.
.
,
,
.
20
10
Reinhart K., Perner A., Sprung Ch.L. et al.
Consensus statement of the ESICM task force on colloid volume therapy
in critically ill patients. Intensive Care Medicine 2012, 38 (3): 368-383
(ESIKM):
>200
21
22
11
63
1980
2004
3359
0,96
(0,78-1,19)
0,93 (0,76-1,15)
Friedrich JO Meta-analysis: low-dose dopamine increases urine output but does
23
not prevent renal dysfunction or death Ann Intern Med. 2005;142:510-524
24
12
(
)
3 in vitro.
Ca+
.
,
).
.
:
.
)
)
.
min
24
.
,
7-9
24
.
25
.
— 6-12
10
,
0,1
<6
.
0,05
.
— 24 .
26
13
27
28
14
–
–
–
–
–
(
)
,
,
,
,
,
29
30
15
25-30
20-25
:
1.
: 30-70%
.
–
.
,
1-2
2.
3.
.
: 20-50%
: 15-20%
.
.
31
.
2,5
35%
Scheinkestel CD, Adams F, Mahony L, et al. Impact of increasing
parenteral protein loads on amino acid levels and balance in critically
ill anuric patients on continuous renal replacement therapy. Nutrition
2003
32
16
[Metnitz PG, Krenn CG, Steltzer H, et
al. Effect of acute renal failure requiring renal
replacement therapy on outcome in critically ill patients.
Crit Care Med 2002; 30: 2051–2058;].
,
24
.
,
,
,
.
33
,
0.8-1.0
,
1.0-
1.5
1,5-1,7
34
17
35
:
4,4-6,1
.
6,1-8,3
.
1-
2
.
36
18
/
.
>27
.
>35,7
>6
>6
>4
37
/
pH > 7.15
pH < 7.15
RIFLE
R
RIFLE
I
RIFLE
F
38
19
:
•
;
•
•
•
;
;
.
39
59±13
61±14
APACH
89±7
85±9
,%
41
32
4,6±1,0
4,9±1,4
3,3±0,4
3,4±0,5
0,92±0,1+6
0,94±0,11
22 (28%)
37 (46%)
0,01
9±2
16±6
0,001
Cr,
,
, Kt/V
,n
(%)
,
Schiffl H. Intermittent hemodialysis and/or continuous renal replacement therapy: are
they complementary or alternative therapies? Am J Kidney Dis. 2002;40(5):1097-9. 40
20
41
.
(
)
42
21
43
44
22
Saudan P et al. Adding a dialysis dose to continuous hemofiltration
increases survival in patients with acute renal failure.Kidney Int.
2006;70(7):1312-7
2000-2003
206
:
1-2,5
1-2,5
, 1-1,5
28
:
90-
39%
:
39%
59%, =0,03
59%, =0,0005
:
71%
78%, =0,62
45
3,9
,
20-25
46
23
, 1908
47
†
†
,
,
†
,
(
),
)
†
†
(
,
†
48
24
1.
2.
3.
4.
,
(
,
,
)
5.
)
6.
7.
(
)
8.
49
25