Department of Intensive Care Medicine, ICU, 2-K12C, Ghent University Hospital, De Pintelaan 185, 9000 Gent, Belgium.
Crit Care. 2012 Jan 19;16(1):201. doi: 10.1186/cc10499.
Acute kidney injury (AKI) in ICU patients is typically associated with other severe conditions that require special attention when renal replacement therapy (RRT) is performed. RRT includes a wide range of techniques, each with specific characteristics and implications for use in ICU patients. In the present review we discuss a wide range of conditions that can occur in ICU patients who have AKI, and the implications this has for RRT. Patients at increased risk for bleeding should be treated without anticoagulation or with regional citrate anticoagulation. In patients who are haemodynamically unstable, continuous therapies are most often employed. These therapies allow slow removal of volume and guarantee a stable blood pH. In patients with cerebral oedema, continuous therapy is recommended in order to prevent decreased cerebral blood flow, which will lead to cerebral ischemia. Continuous therapy will also prevent sudden change in serum osmolality with aggravation of cerebral oedema. Patients with hyponatraemia, as in liver failure or decompensated heart failure, require extra attention because a rapid increase of serum sodium concentration can lead to irreversible brain damage through osmotic myelinolysis. Finally, in patients with severe lactic acidosis, RRT can be used as a bridging therapy, awaiting correction of the underlying cause. Especially in ICU patients who have severe AKI, treatment with RRT requires balancing the pros and cons of different options and modalities. Exact and specific guidelines for RRT in these patients are not available for most clinical situations. In the present article we provide an update on the existing evidence.
ICU 患者的急性肾损伤 (AKI) 通常与其他严重情况相关，在进行肾脏替代治疗 (RRT) 时需要特别注意。RRT 包括广泛的技术，每种技术都具有特定的特征和在 ICU 患者中使用的影响。在本综述中，我们讨论了 ICU 中发生 AKI 的患者可能出现的各种情况，以及这对 RRT 的影响。有出血风险的患者应在不抗凝或使用局部枸橼酸抗凝的情况下进行治疗。对于血流动力学不稳定的患者，通常采用连续治疗。这些疗法可以缓慢去除容量并保证稳定的血液 pH 值。对于脑水肿患者，建议采用连续治疗以防止脑血流量减少，从而导致脑缺血。连续治疗还可以防止血清渗透压的突然变化，从而加重脑水肿。患有低钠血症的患者，如肝衰竭或失代偿性心力衰竭，需要特别注意，因为血清钠浓度的快速增加会通过渗透髓鞘溶解导致不可逆转的脑损伤。最后，对于严重乳酸性酸中毒的患者，RRT 可用作桥接治疗，等待纠正根本原因。特别是对于患有严重 AKI 的 ICU 患者，治疗 RRT 需要权衡不同选择和模式的利弊。对于大多数临床情况，这些患者的 RRT 没有具体的、确切的指南。在本文中，我们提供了现有证据的最新情况。
