1、CRRT Severe sepsis and MODS邱海波东南大学附属中大医院 ICU东南大学急诊与危重医学研究所1. CRRT vs IRRT2. Early vs late CRRT 3. High vs normal flow4.Possible ways to increase mediators clearanceCurrent opinion in CRRT Mode of RRT differences among continentsBellomo, et al. 2001Understanding Renal Replacement Therapy and Acute Re
2、nal Failure in the ICU (The B.E.S.T kidney study) Retrospective cohort study Pats with ARF and required dialysis between April 1,1996, and March 31, 1999 2 ICU in Canada. N=261CRRT对 ARF肾功能恢复的影响 CRRT促进肾功能恢复CRRT IHD PAPACHE II 27 25.1 0.10Baseline SCr 136 180 0.002MAP Before RRT 74.7 87.2 0.001Hosp Mo
3、rtality 71.9% 42.2% 0.01Renal recovery in hosp80.0% 62.5% 0.06Duration of RRT 14.7d 14.5d 0.91Cost per week (Can $)3486-5117 1341Survivor (Cost per y)No-RRTRRT $11,192 $73,273Crit Care Med 2003; 31:449 455IHD vs CRRTICU RRTn=116 RRT for overdosen=7Pre-existing CRFn=16ICU RRT for ARF/MOFn=66Initial C
4、RRTn=66Initial IHDn=28Jacka MJ, Ivancinova X, Gibney RTN. Can J Anaesth 2005;52:327-332 Munns et al观察危重急性肾衰竭患者IHD CRRT CCr下降 25% 7% 尿量下降 50% 10% 钠排泄分数下降 46% 12%肾功能下降的原因 : IHD平均动脉压下降，导致肾脏低灌注，加重肾脏缺血性损伤，延迟急性肾衰竭肾功能的恢复 为什么 CRRT促进肾功能恢复 ? 160 pats with ARF: Daily vs every-other-day IHD Mean ultrafiltration
5、 volume Daily: 1.2 0.5 L Every-other-day: 3.5 0.3 L (P 0.001). Hypotension occurred in Daily: 5 2% Every-other-day: 25 5% (P 0.001) Time to recovery of renal function Daily: 9 2 days Every-other-day:16 6 Days P = 0.001N Engl J Med 2002; 346:305-310为什么 CRRT有助于肾脏功能的恢复？Effect of RRT dose on recovery of
6、 renal function?P = NSRonco C et al. Effects of different doses in CVVH on outcomes of ARF:A prospective RCT20ml/h/kg 35/ml/kg/h 45ml/kg/h95% 92% 90%N=425SurvivalLancet 2000; 356: 26 -30lCRRT vs IRRTon return of renal functionOn mortalityM ortality:Which is better CRRT or IHD?Swzrtz. RD. Comparing c
7、ontinuous HF with HD in patients with severe ARF Am J Kidney 1999; 34: 424 - 432Mehti. RL. Collaborative Group for Treatment of ARF in ICU:A RCT of continuous versus IHD for ARF. Kidney Int 2001; 60: 1154 - 63Kellum JA. Continuous versus intermittent RRT. A meta-analysis. Intensive Care Med 2002; 162: 197- 202 Conclusion :There is no conclusive evidence to support the superiority of CRRT vs IHD. Both techniques are complimentary
