Author: Leo
Keywords: CRRT | continuous renal replacement therapy | renal dysfunction |
shutdown
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| From google images |
The incidence of acute renal injury (AKI) in hospitalized patients was high, 21.6% for adults and 33. 7% for children. The mortality rate of adult patients with AKI was as high as 23.9%.
The incidence of acute renal injury (AKI) in hospitalized patients was high, 21.6% for adults and 33. 7% for children. The mortality rate of adult patients with AKI was as high as 23.9%.
Continuous renal replacement therapy (CRRT) is the primary alternative to kidney treatment for severe AKI due to the superiority of hemodynamic stability and solute capacity management. CRRT in the treatment of severe AKI, multiple organ dysfunction, systemic inflammatory response syndrome and other clinical work more and more attention and application. There have been relevant studies to discuss the timing of CRRT, mode selection, prescription dose and so on.
CRRT downtime is still lack of sufficient research.
CRRT shutdown need to be careful, premature discontinuation often inadequate treatment, easy to lead to adverse prognosis. However, excessive renal replacement therapy (RRT) not only increases the cost of medical care, but also increases the risk of complications such as bleeding and infection. The 2012 Guidelines for the Improvement of Global Kidney Disease Prognosis (KDIGO) suggest that the downtime of CRRT in AKI patients is of no interest and its definition of downtime is also very vague.
At present, the main clinical diagnosis based on urine output, serum creatinine and in vivo steady-state balance. The patient's urine itself is not always associated with the ability of the kidneys to remove solutes, such as non-oliguric AKI, and urine output is affected by rehydration and diuretics, and does not fully reflect renal function. Because creatinine is cleared during CRRT treatment, its level is used to directly evaluate the recovery of renal function remains to be verified.
Recent studies suggest that AKI biomarker levels should be used as one of the criteria for downtime. Now on the AKI patients with urine output, creatinine, biomarkers and other aspects of the CRRT downtime to do an overview.
First, urine output
Physiological state, the urine output reflects the glomerular filtration rate and renal tubular reabsorption, concentration and dilution function. Normal adults daily urine output of 1500-2000mL, less than 400mL daily urine called less urine.
Although many factors have an impact on urine output, clinical urine output is still an important indicator of renal function recovery and predictive shutdown. Uchino and other recent multi-center large sample studies have pointed out that urine output is the best indicator of the timing of downtime, the study data show that the success of the shutdown group before the day off more than the repeated amount of urine (1500mL than 180mL).
Another retrospective study also showed that the CRRT successful shutdown group had more urine output on the day of the shutdown and the sequential organ failure score (SOFA) was an independent predictor of the repeated reduction in the amount of urine And SOFA values are important factors for successful downtime. CRRT is in principle a continuous process, but the implementation process will inevitably be interrupted, such as conventional replacement of disposable materials and clogged due to clogging of the filter pipe and so on.
Second, creatinine
1. Urine creatinine clearance: creatinine is a small molecule material, can be through the glomerular filtration into the urine, rarely absorbed in the renal tubules. Urine creatinine clearance rate as an indicator of renal function, can effectively reflect the GFR.
2h urinary creatinine clearance rate by measuring 2h urine output, urine creatinine and serum creatinine level calculated in the actual operation easier to obtain, and a short period of time is not susceptible to decreased renal function.
24h urinary creatinine clearance rate by measuring 24 h urine, urine creatinine and serum creatinine level obtained, refers to the AKI patients with non-oligurative serum creatinine removal efficiency, in the case of stable CFR can accurately reflect the kidney clearance creatinine and other solute capacity. Clinical use of 24 h urinary creatinine clearance rate to assess glomerular filtration function, but requires patients with renal function within 24 h is relatively stable, its application is quite limited.
2. Serum creatinine: Clinical serum creatinine is usually used as an indicator of glomerular filtration function.
In patients with CRRT serum creatinine can be effectively removed, the level of serum creatinine in patients with renal function and CRRT clearance in two aspects. However, Uchino and other multi-center studies have shown that serum creatinine in the predicted stop AUCROC 0.365, indicating its accuracy is acceptable, is second only to the urine output of the predicted CRRT shutdown indicators. Cruz and other studies suggest that patients with urine and serum creatinine recovery to the baseline level is CRRT downtime.
Third, other biomarkers
The biomarkers of AKI include neutrophils gelatinase-related lipid transport protein (NGAL), cystatin C and renal injury molecule-1 (KIM-1), IL-18 (Such as NCAL and cystatin C relative molecular mass were 25000 and 13000, respectively, is not easy to clear in the CRRT, can be more accurately reflect the CRRT treatment of AKI patients with renal function levels.
Recent studies have suggested that biomarkers such as NGAL and cystatin C are more sensitive to serum creatinine in the assessment of renal impairment.
1. NGAL: NGAL by glomerular filtration, through the proximal tubule completely removed. Serum NGAL is a predictor of early renal function recovery in patients receiving CRRT.
Urinary NGAL elevation is mainly caused by impaired renal tubular function. In the presence of AKI, urine can be detected soon NGAL.
It should be noted that elevated levels of NGAL can also be detected in patients with cardiovascular and cerebrovascular diseases and respiratory diseases, suggesting that NCAL specificity is lacking. Urinary NGAL is not commonly used as a stop indicator in clinical practice. Urine NCAL and renal function also need a large sample of prospective study to further demonstrate.
2. Cystatin C: Cystatin C is produced by the body's nucleated cells and is a constant endogenous marker.
Circulation of cystatin C by glomerular filtration was removed in the proximal tubule after reabsorption was completely metabolized decomposition, do not return to the blood. The concentration of blood is not affected by any external factors (such as sex, age, diet, etc.), is to reflect the GFR changes in the ideal homology markers.
Cystatin C is a relative molecular mass molecule that is partially cleared in CRRT, typically no more than 30010. Urinary cystatin C content determined by the CFR. In animal models that received cisplatin intravenous injection, urinary cystatin C sensitively detects the incidence of AKI.
CRRT's timing is particularly important, and proper downtime is not only beneficial for early recovery of renal function, but also to reduce unnecessary medical risks, treatment costs and length of stay. Urine output is currently judged CRRT shutdown better indicators, but in the shutdown should try to avoid diuretics and CRRT ultrafiltration impact. Since creatinine itself can be cleared by CRRT, the level of creatinine does not accurately reflect the ability of the kidney itself to remove solutes.
(Such as NGAL), the change in concentration (serum or urine) can clearly reflect the ability of the patient's kidney itself to remove solute during the treatment of CRRT, due to the fact that the relatively high molecular weight AKI biomarker (eg NGAL) As a predictor of future CRRT downtime. The combination of urine and biomarkers for CRRT shutdown should be more accurate and should be expected in future studies.
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