Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Clin J Am Soc Nephrol. 2023 Jun 1;18(6):788-802. doi: 10.2215/CJN.0000000000000164. Epub 2023 Apr 5.
While the administration of intravenous fluids remains an important treatment, the negative consequences of subsequent fluid overload have raised questions about when and how clinicians should pursue avenues of fluid removal. Decisions regarding fluid removal during critical illness are complex even for patients with preserved kidney function. This article seeks to apply general concepts of fluid management to the care of patients who also require KRT. Because optimal fluid management for any specific patient is likely to change over the course of critical illness, conceptual models using phases of care have been developed. In this review, we will examine the implications of one such model on the use of ultrafiltration during KRT for volume removal in distributive shock. This will also provide a useful lens to re-examine published data of KRT during critical illness. We will highlight recent prospective trials of KRT as well as recent retrospective studies examining ultrafiltration rate and mortality, review the results, and discuss applications and shortcomings of these studies. We also emphasize that current data and techniques suggest that optimal guidelines will not consist of recommendations for or against absolute fluid removal rates but will instead require the development of dynamic protocols involving frequent cycles of reassessment and adjustment of net fluid removal goals. If optimal fluid management is dynamic, then frequent assessment of fluid responsiveness, fluid toxicity, and tolerance of fluid removal will be needed. Innovations in our ability to assess these parameters may improve our management of ultrafiltration in the future.
尽管静脉输液仍然是一种重要的治疗方法，但随后出现的液体超负荷的负面后果引发了人们对于何时以及如何通过去除液体来治疗的疑问。即使对于肾功能正常的患者，在危重病期间做出关于液体去除的决策也是复杂的。本文旨在将一般的液体管理概念应用于需要接受肾脏替代治疗（KRT）的患者的护理中。由于任何特定患者的最佳液体管理可能会在危重病期间发生变化，因此已经开发出了使用护理阶段的概念模型。在本次综述中，我们将研究此类模型对使用超滤进行分布性休克容量去除的影响。这也将为重新审视危重病期间 KRT 的已发表数据提供有用的视角。我们将重点介绍最近的前瞻性 KRT 试验以及最近关于超滤率和死亡率的回顾性研究，回顾其结果，并讨论这些研究的应用和局限性。我们还强调，当前的数据和技术表明，最佳指南不会包括对绝对液体去除率的推荐或反对，而是需要制定涉及频繁重新评估和调整净液体去除目标的动态方案。如果最佳液体管理是动态的，那么就需要频繁评估液体反应性、液体毒性以及对液体去除的耐受性。我们评估这些参数的能力的创新可能会在未来改善我们对超滤的管理。
