Injuria renal aguda Casa de Galicia
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Transcript of Injuria renal aguda Casa de Galicia
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• Nuevas definiciones de IRA
• Importancia de la IRA
• Remplazo renal:
-Cuando? Precoz vs Tardía
-Modalidad? HDI, HDE, HF, HDF, DP
-Intensidad
-Accesos
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2003
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Urinary
biomarkers
Subclinical
AKI
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• 71000 pacientes
• Criterios RIFLE
• Mortalidad en AKI 31.2% vs 6.9% en no AKI
• Mortalidad
-RISK : 18.9%
-INJURY : 36.1%
-FAILURE : 46.5%
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• Mayor mortalidad en grupo de días alternos
• Mayor demora en resolución de la IRA
• Critica: dosis muy baja de diálisis
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• Unicéntrico
• Prospectivo
• Randomizado
• CVVHDF
• G1: 20ml/kg/h
• G2: 35ml/kg/h G2: G235ml/kg/h
• G3: 40ml/kg/h
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Mortalidad significativamente mayor en G1 versus G2 y G3 (p<0.001)
Sin diferencia entre G2 y G3
Dosis recomendada > 35ml/kg/h
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• Randomizado
• 80 pacientes
• CVVHD
• IHD(hasta + 6hrs)
• KTV objetivo 3.6
• UF signif mayor
• IHD caída PAM
• Mortalidad =
• Recuperación renal =
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• Balance de fluídos (3 días)
• CVVHD
- 4005ml ( -13533 a + 6745ml )
• IHD
+ 1539ml ( - 5510 a + 9152ml )
p< 0.001
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• Presión arterial media
• CVVHD
PAM pre 76.8+- 7.8mmHg
PAM intra dial 77.4+- 8.1mmHg
p NS
• IHD
PAM pre 77.6+- 12.9mmHg
PAM intra dial 75+- 13.8mmHg
p = 0.04
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• Hemodiafe Study : Randomizado – Multicéntrico
• CVVHDF vs IHD
• Ptes críticos con IRA formando parte de DOM
• Inclusión:
-Azoemia > 216mg/dl
-Creatininemia > 3.5mg/dl
-Oliguria – diuresis < 360ml en 16hrs
-Necesidad de TRR
-DOM con LOD(logistic organ disfunction score) > 6
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• La presencia de Sepsis fue significativa en el grupo de IHD
• La media de duración en IHD fue mayor a 4hrs
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• Igual sobrevida – D28, D60, D90
• Recuperación de función renal igual
• Ppal crítica : 29ml/kg/h de dosis de diálisis
en el grupo de CVVHD
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• Intensivo: CVVHDF 35ml/kg/h, SLED o HD – 6 veces/semana
• Menos intensivo: CVVHDF 20ml/kg/h, SLED o HD – 3 veces/semana
• KTV 1.2 – 1.4 / sesión en ambos grupos
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• End point primario: no hubo diferencias en la mortalidad a los 60 días de seguimiento
• End point secundarios: recuperación de la función renal sin diferencia significativa
• Complicaciones: significativamente mas hipoK e hipoP en grupo intensivo
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• Randomizado
• Multicéntrico
• 1508 ptes
• CVVHDF
-25ml/kg/h
-40ml/kg/h
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• Randomizado
• 120 pacientes críticos
• DP de alto volumen (KTV semanal 3.6) vs HD diaria
• Cat Tenckhoff – ciclador -18 a 22 recambios diarios 2000cc Dext 1.5%
• Criterios de inicio de TRR: sintomas uremicos, azoemia > 125mg/dl,
hipervolemia refractaria a diuréticos, disionías y acidosis severa
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• Ambos grupos tienen
características similares
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• Randomizado
• Multicéntrico
• 750 pacientes
• CDL – Yug vs Femoral
• Colonización de catéter al
momento del retiro (>100 UFC)
• Bacteriemia asociada a cateter
• Complicaciónes en inserción
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Fem:
38/102(37.2%)
Yug:
22/100(22%)
Fem:
25/101(24.8%)
Yug:
28/101(27.1%)
Fem:
18/101(17.8%)
Yug:
25/94(26.6%)
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