Renal Replacement Therapy For Acute Kidney Injury? The Guide Recommends Reading It Quickly!

Renal replacement therapy (RRT) is one of the main methods of treatment for acute kidney injury (AKI). The ideal RRT treatment mode for AKI patients is to slowly and gently remove toxins, adjust volume balance, and avoid significant fluctuations in hemodynamics as much as possible. Simulate the physiological process of the human kidney. Regarding renal replacement therapy for AKI, the "Chinese Clinical Practice Guidelines for Acute Kidney Injury" mainly makes the following recommendations.

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Selection and maintenance of vascular access in AKI

1. For AKI patients who plan to undergo RRT, it is recommended that specialist physicians intervene to systematically evaluate the current condition and RRT plan, and formulate a complete vascular access plan (1C).

2. Before catheterization, ultrasound must be used to evaluate the vascular conditions of the proposed catheterization site. The right internal jugular vein and femoral vein are recommended as the preferred catheterization sites. Indwelling subclavian vein catheters are not recommended (1A). For patients with a body mass index (BMI) >28.4kg/m2, the internal jugular vein is recommended as the preferred catheter placement site. For patients with a BMI <24.0 kg/m2, the femoral vein is recommended as the preferred catheter placement site (2B). The femoral vein is recommended as the preferred catheterization site for patients with known severe respiratory tract disease (1C).

3. For patients with expected RRT time <1 month, it is recommended to use dialysis catheters (NCC) without tunnels and polyester sleeves as vascular access; for patients with expected RRT time >3 months, or patients with long-term RRT needs, it is recommended to use dialysis catheters with Tunneled and Dacron-sheathed dialysis catheters (TCCs) as vascular access or prompt replacement of NCCs with TCCs (1A).

4. It is recommended that normal adult patients use a dual-lumen NCC with a circumference of 10 to 12 Fr or a dual-lumen TCC with a circumference of 11 to 14 Fr as the vascular access for RRT (1B).

5. It is recommended to perform puncture and catheterization to establish vascular access in a sterile operating room or operating room under ECG monitoring (1A); for AKI patients in the ICU, it is recommended to perform bedside catheterization in accordance with sterile operating standards (2B).

6. It is recommended to perform puncture and catheterization to establish vascular access under ultrasound localization or real-time ultrasound guidance; after completion of catheterization, chest or abdominal radiographs are taken to confirm the position of the catheter tip (1A).

7. It is recommended to take care of the catheter puncture site and the outer port of the TCC before each blood purification treatment, and to use an appropriate sealing solution to seal the tube after each treatment (1A); it is recommended to use ordinary sealing fluid with a concentration of 10 mg/ml or above. Heparin solution or 4% to 30% citric acid solution is used as a locking solution to prevent intracatheter thrombosis (1B).

8. In case of poor catheter function, it is recommended to use at least 5 000~10000 U/ml single-chain urokinase or 1~2 mg/ml tissue plasminogen activator (t-PA) on the premise of ruling out poor catheter position. Thrombolytic therapy. If thrombolytic treatment is ineffective, it is recommended to perform in situ catheter replacement under guidewire guidance after excluding the catheter tip thrombus (2B).

9. If catheter-related infection occurs, NCC patients are recommended to have the catheter removed immediately and the catheter tip cultured. If TCC patients only have external mouth infections, local and systemic antibiotic treatment can be considered. If there is tunnel- and catheter-related bacteremia, it is recommended to remove the catheter immediately. Remove the catheter. If the patient needs to continue blood purification treatment, it is recommended to reuse the NCC to establish vascular access after changing the position. If the patient still has symptoms of systemic infection after extubation, it is recommended to use sensitive antibiotics for 1 to 2 weeks of treatment based on the culture results (2B).

Anticoagulation therapy for blood purification in AKI patients

1. For AKI patients who require blood purification, the patient's coagulation status should be assessed before blood purification treatment, and anticoagulants and their doses should be selected reasonably (expert consensus).

2. For patients with hypercoagulant activity and/or thromboembolic risks or diseases, except for patients with contraindications to heparin drugs, it is recommended to use unfractionated heparin or low molecular weight heparin; if necessary, unfractionated heparin or low molecular weight heparin can be used as basic anticoagulant therapy (2B ). For patients with previous or combined heparin-induced thrombocytopenia (HIT), except for patients with contraindications to citrate or argatroban, it is recommended to choose topical citrate or argatroban for anticoagulation; use danaparin sodium with caution; Fondaparinux is not recommended (1A).

3. For patients with active bleeding or high-risk bleeding, excluding patients with contraindications to citrate, topical citrate anticoagulation is preferred (1A); for patients with contraindications to citrate, excluding those with contraindications to argatroban, It is recommended to choose argatroban (2B); for patients with contraindications to citrate or argatroban, except for nafamostat mesylate contraindications, it is recommended to choose nafamostat mesylate; If mostostat is contraindicated, blood purification treatment can be performed without anticoagulants (2B).

4. It is recommended that the dose of anticoagulant drugs be selected individually and adjusted based on the monitoring results of the patient's internal and extracorporeal coagulation status during blood purification treatment and the internal coagulation status after treatment (expert consensus).

5. When adverse events occur during anticoagulation therapy, the patient's coagulation status should be re-evaluated, anticoagulant drugs and their dosage should be re-selected, and adverse reactions should be treated (expert consensus).

Timing to start and stop RRT in patients with AKI

1. Indications for emergency RRT in AKI: volume overload, hyperkalemia (serum potassium >6.5mmol/L), uremic symptoms, including uremic pericarditis, uremic encephalopathy or other unexplained decreases in consciousness, severe metabolism Sexual acidosis (pH<7.1) (expert consensus).

2. Early initiation of RRT treatment is not recommended for patients with AKI (1B).

3. The timing of starting RRT for AKI depends on the patient's clinical manifestations and disease status (expert consensus).

4. When the AKI patient's own renal function recovers to meet the patient's needs or when RRT and treatment goals are inconsistent, discontinuation of RRT treatment can be considered (expert consensus).

Selection and application of RRT mode in AKI patients, and principles of treatment mode selection

1. There is no difference in clinical benefits between intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) in patients with AKI (1B).

2. For patients with hemodynamic instability, CRRT is recommended instead of IHD (1B).

hemodialysis treatment

1. Recommended indications for IHD treatment include: serum potassium >6.0mmol/L or persistent tissue damage, such as rhabdomyolysis, crush injury, etc.; serum potassium >5.5mmol/L; severe metabolic acid still exists after alkali supplementation treatment Poisoning (pH<7.2); severe volume overload despite high-dose diuretic therapy; hemodynamically stable AKI patients (1A).

2. It is recommended that contraindications to IHD include: patients with hemodynamic instability, increased intracranial pressure, and cerebral edema caused by various causes (2D).

3. The recommended IHD treatment plan is 3 times a week or once every other day, and the dialysis treatment dose has a urea clearance index (Kt/V) ≥ 1.2/time (1B).

CRRT treatment

1. Recommended indications for CRRT include AKI patients with hemodynamic instability or AKI patients with elevated intracranial pressure and extensive cerebral edema caused by acute brain injury or other causes (2B).

2. There are no absolute contraindications to CRRT. It is recommended that it should be used with caution in the following situations: (1) Unable to establish appropriate vascular access; (2) Hypotension that is difficult to correct; (3) Cachexia, such as malignant tumors with systemic metastasis (3D).

3. The recommended CRRT replacement fluid flow rate is 20~25 ml·kg-1·h-1 (2B).

Special blood purification technology

1. It is recommended that extended intermittent RRT (PIRRT) is suitable for AKI patients who are hemodynamically unstable cannot tolerate standard IHD treatment and require dialysis (2D).

2. CRRT, including PIRRT, is recommended for AKI patients with elevated intracranial pressure caused by acute brain injury or other causes (2D).

3. SLED can be applied to hemodynamically unstable AKI (2B), post-surgical AKI (2C), and severe AKI combined with tumors (2C).

Combination Blood Purification Treatment

1. It is not recommended to use two CRRT devices in series to complete the hybrid blood purification mode (2A).

2. Endotoxin adsorption technology is recommended for patients with sepsis or septic shock infected by Gram-negative bacteria, especially patients with septic shock and AKI after abdominal surgery (2B).

3. Routine use of high-volume hemofiltration is not recommended in patients with septic AKI (1A).

4. Hemoperfusion and plasma adsorption technology can be used to remove protein-bound toxins or medium-to-large molecular toxins from the body (2C).

5. Extracorporeal CO2 scavenging technology can be used in patients with difficult-to-correct hypercapnia combined with AKI to help reduce ventilator-related lung injury (2C).

6. Artificial liver technology can be used for AKI patients with liver failure (2C).

7. Plasma exchange and double-membrane plasma exchange (DFPP) can be used to remove protein-bound toxins or macromolecular toxins from the body, and DFPP can be used to remove blood lipids (2B).

peritoneal dialysis

1. It is recommended that peritoneal dialysis treatment be feasible for the following AKI patients, including: (1) Hemodialysis or CRRT is not available in the area where the AKI patient is located; (2) High-risk bleeding risk; (3) No vascular access; (4) Heart failure ineffective in drug treatment And those who require dialysis; (5) Patients with cirrhosis and large amounts of ascites (2D).

2. Peritoneal dialysis treatment is not recommended for the following AKI patients, including: (1) with a history of previous abdominal surgery; (2) with thoracoperitoneal leakage, abdominal infection, or abdominal wall cellulitis; (3) with severe dyspnea; (4) Patients with rapid increase in serum potassium (2D).

How Does Cistanche Treat Kidney Disease?

Cistanche is a traditional Chinese herbal medicine used for centuries to treat various health conditions, including kidney disease. It is derived from the dried stems of Cistanche deserticola, a plant native to the deserts of China and Mongolia. The main active components of cistanche are phenylethanoid glycosides, echinacoside, and acteoside, which have been found to have beneficial effects on kidney health.

Kidney disease, also known as renal disease, refers to a condition in which the kidneys are not functioning properly. This can result in a buildup of waste products and toxins in the body, leading to various symptoms and complications. Cistanche may help treat kidney disease ase through several mechanisms.

Firstly, cistanche has been found to have diuretic properties, meaning it can increase urine production and help eliminate waste products from the body. This can help relieve the burden on the kidneys and prevent the buildup of toxins. By promoting diuresis, cistanche may also help Reduce high blood pressure, a common complication of kidney disease.

Moreover, cistanche has been shown to have antioxidant effects. Oxidative stress, caused by an imbalance between the production of free radicals and the body's antioxidant defenses, plays a key role in the progression of kidney disease. ies help neutralize free radicals and reduce Oxidative stress, thereby protecting the kidneys from damage. The phenylethanoid glycosides found in cistanche have been particularly effective in scavenging free radicals and inhibiting lipid peroxidation.

Additionally, cistanche has been found to have anti-inflammatory effects. Inflammation is another key factor in the development and progression of kidney disease. Cistanche's anti-inflammatory properties help reduce the production of pro-inflammatory cytokines and inhibit the activation of inflammation mandatory pathways, thus alleviating inflammation in the kidneys.

Furthermore, cistanche has been shown to have immunomodulatory effects. In kidney disease, the immune system can be dysregulated, leading to excessive inflammation and tissue damage. Cistanche helps regulate the immune response by modulating the production and activity of immune cells, such as T cells and macrophages. This immune regulation helps reduce inflammation and prevent further damage to the kidneys.

Moreover, cistanche has been found to improve renal function by promoting the regeneration of renal tubes with cells. Renal tubular epithelial cells play a crucial role in the filtration and reabsorption of waste products and electrolytes. In kidney disease, these cells can be damaged, leading to damaged renal function. Cistanche's ability to promote the regeneration of these cells helps restore proper renal function and improve overall kidney health.

In addition to these direct effects on the kidneys, cistanche has been found to have beneficial effects on other organs and systems in the body. This holistic approach to health is particularly important in kidney disease, as the condition often affects multiple organs and systems. che has been shown to have protective effects on the liver, heart, and blood vessels, which are commonly affected by kidney disease. By promoting the health of these organs, cistanche helps improve overall kidney function and prevent further complications.

In conclusion, cistanche is a traditional Chinese herbal medicine used for centuries to treat kidney disease. Its active components have diuretic, antioxidant, anti-inflammatory, immunomodulatory, and regenerative effects, which help improve renal function and protect the kidneys from further damage. , cistanche has beneficial effects on other organs and systems, making it a holistic approach to treating kidney disease.