334.2 🩺 國考版

334.2.1 高頻考點

334.2.1.1 RRT Indications (AEIOU)

  • Acidosis severe refractory
  • Electrolyte (K > 6.5 refractory)
  • Ingestion (toxins)
  • Overload (volume refractory)
  • Uremia (encephalopathy, pericarditis, bleeding)

334.2.1.2 RRT Modalities Comparison

Modality Setting Hemodynamic Anticoag
IHD Stable Tolerates Heparin or citrate
CRRT Unstable Better tolerated Heparin or citrate preferred
SLED Intermediate Intermediate Heparin or citrate
PD Acute (rare) Variable None

334.2.1.3 Vascular Access

  • Acute: CVC (IJ > femoral > subclavian)
  • Tunneled vs non-tunneled
  • Chronic: AV fistula > graft

334.2.1.4 Citrate Regional Anticoagulation

  • Preferred for bleeding risk, HIT
  • Complications: hypocalcemia, alkalosis, citrate accumulation (liver failure)
  • Monitor ionized Ca + total Ca + gap + pH

334.2.1.5 Timing of RRT

  • STARRT-AKI 2020: accelerated vs standard — no mortality benefit
  • AKIKI 2016, IDEAL-ICU 2018: similar
  • Practice: indication-driven, not arbitrary numbers

334.2.1.6 Removable Toxins

  • Methanol, ethylene glycol
  • Lithium
  • Salicylates
  • Metformin
  • Vancomycin (some)
  • Aluminum

334.2.1.7 Drug Dosing in AKI / RRT

  • Many antibiotics need dose adjustment
  • Vancomycin: timed with HD
  • Aminoglycosides: post-HD
  • Drugs requiring monitoring: levels critical

334.2.1.8 Recovery Predictors

  • Severity of AKI
  • Cause (drug > sepsis > ATN-ischemic)
  • Age, comorbidities
  • Need for RRT
  • Pre-existing CKD

334.2.2 易混淆比范

Type Best For Pros Cons
IHD Stable Rapid Hemodynamic instability
CRRT Unstable Gradual Resource, anticoag
SLED Intermediate Mid-ground Less common
PD Pediatric, low-resource Simple Slow

334.2.3 Special Topics

334.2.3.1 Disequilibrium Syndrome

  • Rapid solute removal → cerebral edema
  • Headache, nausea, seizures, coma
  • Prevention: slower initial sessions, lower flow
  • More common with first dialysis, severe uremia

334.2.3.2 Diuretic Resistance in CRS

  • Mechanisms: hypoalbuminemia, GI absorption issues, RAS activation, NSAIDs
  • Solutions: IV loop, double dose, add thiazide (synergistic, e.g., metolazone), tolvaptan, acetazolamide
  • Ultrafiltration if refractory