334.4 📋 章末速記 Summary

334.4.1 🔑 一句話總結

AKI management 三大支柱：(1) address cause：volume resuscitation (crystalloid, albumin in HRS, balanced solutions BaSICS/SMART), hold nephrotoxins, treat sepsis, decompress obstruction, IS for GN/AIN, terlipressin + albumin for HRS (FDA 2022)；(2) supportive care：fluid/electrolyte/acid-base (hyperkalemia priority + bicarb if pH < 7.1 BICAR-ICU), nutrition (no protein restriction; 1.2-1.5 g/kg on RRT), drug dosing adjustment, DVT prophylaxis；(3) RRT when indicated — AEIOU mnemonic：Acidosis refractory, Electrolyte (K > 6.5), Ingestion (removable toxins), Overload (volume refractory), Uremia (encephalopathy, pericarditis, bleeding)；modalities：IHD (intermittent HD) for stable, CRRT (CVVH/CVVHD/CVVHDF) for unstable ICU patients (gradual + hemodynamic stability), SLED hybrid, PD rare in adult AKI；vascular access: CVC (IJ > femoral > subclavian) acute, AV fistula chronic preferred；anticoagulation：citrate regional preferred for bleeding/HIT (complications: hypoCa + alkalosis + accumulation in liver failure)；STARRT-AKI 2020 + AKIKI + IDEAL-ICU：no mortality benefit to early RRT; indication-driven；outcomes：30-50% in-hospital mortality if RRT needed；70-80% renal recovery；post-AKI surveillance important (↑ CKD progression risk)。

334.4.2 💊 治療精要

  • fluid resuscitation：balanced crystalloids (LR, Plasma-Lyte) > 0.9% saline (BaSICS, SMART); albumin in HRS / hypoalbuminemia
  • hyperkalemia：Ca gluconate (membrane) → insulin/glucose + bicarb (if acidotic) + β2-agonist → K binders (patiromer, SZC) → RRT
  • HRS：terlipressin + albumin (FDA 2022) or norepinephrine + albumin
  • diuretic resistance in CRS：IV loop ↑ dose + add thiazide (metolazone) + acetazolamide (ADVOR) + tolvaptan + ultrafiltration
  • RRT modality selection：unstable → CRRT；stable → IHD；intermediate → SLED；severe overload → ultrafiltration
  • anticoagulation：citrate regional preferred (bleeding/HIT); monitor ionized Ca, total Ca, gap > 2.5 → citrate accumulation
  • drug dosing in HD/CRRT：vancomycin post-HD, aminoglycosides extended interval, β-lactams continuous infusion in critically ill
  • TLS prevention：rasburicase (high-risk) or allopurinol (low/intermediate) + hydration
  • post-AKI：clinic + periodic eGFR/UACR + CKD prevention

334.4.3 🎯 盧醫師的考前提醒

  1. RRT 5 indications (AEIOU)：Acidosis (pH < 7.1 refractory)、Electrolyte (K > 6.5 refractory)、Ingestion (methanol/ethylene glycol/lithium/salicylate/metformin)、Overload (volume refractory)、Uremia (encephalopathy/pericarditis/bleeding)
  2. STARRT-AKI 2020 + AKIKI 2016 + IDEAL-ICU 2018 都顯示 early RRT no mortality benefit；practice 從 numeric thresholds 改成 indication-driven
  3. IHD vs CRRT 選擇：hemodynamically stable → IHD；unstable (shock, multiple organ dysfunction) → CRRT (continuous + gradual)；SLED 為 hybrid
  4. citrate regional anticoagulation for CRRT: preferred for bleeding risk + HIT；complications = hypocalcemia (citrate binds Ca) + metabolic alkalosis + citrate accumulation in liver failure (monitor gap > 2.5 = ratio total/ionized Ca)
  5. fluid resuscitation choice：balanced solutions (Lactated Ringers, Plasma-Lyte) > 0.9% saline per BaSICS + SMART trials；avoid hetastarch (renal failure)
  6. disequilibrium syndrome：rapid solute removal → cerebral edema → HA, nausea, seizures, coma；more common at first dialysis with severe uremia；prevention = slower initial sessions
  7. diuretic resistance in cardiorenal syndrome：IV loop ↑ dose → add thiazide (metolazone, synergistic) → acetazolamide (ADVOR) → tolvaptan → ultrafiltration if refractory
  8. HRS treatment：terlipressin + albumin (CONFIRM 2021, FDA 2022) is breakthrough；alternative norepinephrine + albumin in ICU；liver transplant cure
  9. vascular access for acute RRT：CVC IJ > femoral > subclavian (subclavian last due to stenosis affecting future AV fistula creation in long-term)
  10. post-AKI long-term surveillance critical：AKI accelerates CKD progression；70-80% recover but periodic eGFR + UACR + CKD prevention; ACE/ARB and SGLT2i may help slow progression