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中华肾病研究电子杂志 ›› 2026, Vol. 15 ›› Issue (01) : 1 -7. doi: 10.3877/cma.j.issn.2095-3216.2026.01.001

指南与共识

2025年法国重症监护室中急性肾损伤的肾脏替代治疗指南解读
倪琛, 邬步云, 毛慧娟()   
  1. 210029 南京医科大学第一附属医院(江苏省人民医院)肾内科
  • 收稿日期:2025-09-01 出版日期:2026-02-28
  • 通信作者: 毛慧娟
  • 基金资助:
    四大慢病国家科技重大专项(2025ZD0547600)

Interpretation of the 2025 French guideline for renal replacement therapy of acute kidney injury in intensive care units

Chen Ni, Buyun Wu, Huijuan Mao()   

  1. Department of Nephrology, First Affiliated Hospital of Nanjing Medical University (Jiangsu Provincial People′s Hospital), Nanjing 210029, Jiangsu Province, China
  • Received:2025-09-01 Published:2026-02-28
  • Corresponding author: Huijuan Mao
引用本文:

倪琛, 邬步云, 毛慧娟. 2025年法国重症监护室中急性肾损伤的肾脏替代治疗指南解读[J/OL]. 中华肾病研究电子杂志, 2026, 15(01): 1-7.

Chen Ni, Buyun Wu, Huijuan Mao. Interpretation of the 2025 French guideline for renal replacement therapy of acute kidney injury in intensive care units[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2026, 15(01): 1-7.

肾脏替代治疗(renal replacement therapy,RRT)虽已在重症监护病房(intensive care unit,ICU)中广泛使用,但其在急性肾损伤(acute kidney injury,AKI)患者中的应用仍缺乏统一规范。2024年11月,法国重症医学会联合法国儿科重症与急救协作组召开共识会议,发布了面向成人及儿童AKI患者的循证指南。该指南系统更新了ICU中RRT的管理策略,强调无紧急指征时延迟启动RRT、各模式预后等效以及资源受限时腹膜透析的可行性,明确高氨血症患儿的RRT启动指征。在实施层面上提出成人剂量偏保守、儿科剂量个体化;不推荐高出血风险患者使用肝素封管,同时重视血容量管理与每日撤机评估。本文对该指南的主要推荐进行梳理和解读,并探讨其对我国RRT规范化管理的启示。

Renal replacement therapy (RRT) is widely used in the intensive care unit (ICU), but its application in patients with acute kidney injury (AKI) still lacks unified standards. In November 2024, the French Society of Intensive Care Medicine, in collaboration with the French Pediatric Critical Care and Emergency Group, published an evidence-based guideline for both adult and pediatric patients with AKI. This guideline systematically updates the management strategies for RRT in the ICU. It emphasizes the deferral of RRT initiation in the absence of emergent indications, the equivalence of outcomes across different RRT modalities, and the feasibility of peritoneal dialysis under resource constraints, while specifying the initiation indications for pediatric patients with hyperammonemia. At the implementation level, it proposes a conservative dosing regimen for adults and an individualized approach for pediatric patients. Furthermore, it does not recommend heparin locking for patients at high risk of bleeding, highlighting the importance of blood volume management and daily weaning assessments. This article reviews and interprets the main recommendations of the guideline, and discusses their implications for the standardized management of RRT in China.

表1 GRADE方法学推荐分级标准
表2 高钾血症快速恶化的高风险情形
表3 本指南与2012 KDIGO-AKI指南对比
关键问题 2012 KDIGO-AKI指南核心观点 本指南新观点
成人 儿童
适应症与启动时机 当存在危及生命的水、电解质、酸碱紊乱时,紧急启动RRT;不推荐依赖BUN/Cr阈值,需结合临床背景 细化RRT启动时机:关注高钾血症快速恶化风险,避免以代谢性酸中毒作为唯一启动指征。血尿素>40 mmol/L且无肾功能恢复迹象,可考虑启动RRT;无紧急指征者可观察72 h后考虑启动。急性中毒需联系毒理学专家个体化评估 若利尿后体液潴留仍超过体重的10%,可考虑启动RRT。新生儿或迟发型高氨血症患者,当血氨>500 μmol/L或250~500 μmol/L伴明显脑病或药物治疗无效者,建议启动RRT
模式选择 血流动力学不稳定、颅内高压患者应首选CRRT CRRT、IHD及杂合模式预后相当,治疗选择应综合团队经验、设备可用性及环境影响。血管通路可用时不推荐PD,而资源受限且血管通路建立困难时,PD可作为替代方案 血流动力学不稳定者优先CRRT;稳定者根据团队专长与设备条件选择。非危及生命时,PD可替代CRRT
透析剂量 剂量需满足电解质、酸碱和水平衡需求。CRRT推荐20~25 ml/(kg·h),间断RRT每周Kt/V应达到3.9 推荐成人CRRT最大处方剂量为25 ml/(kg·h)。不建议增加透析频率或每周Kt/V超过3.9 常规推荐25~35 ml/(kg·h)的处方剂量。中毒合并高氨血症、感染性休克时可>50 ml/(kg·h)
处方与监测 建议透析液或置换液使用碳酸盐缓冲液,并确保质量符合美国医疗器械协会的细菌与内毒素标准。建议序贯评估实际剂量,但未涉及具体监测措施 建议起始使用高钠(150~160 mmol/L)、低温(低于体温1.5~2 ℃)透析液以改善血流动力学耐受性。不推荐自动生物反馈控制设备;重视血容量评估,透析中低血压时应停止超滤。不推荐使用高截留膜 无独立推荐,参照成人方案
血管通路 优先临时导管;建议超声引导下置管,部位首选右颈内、股静脉,颈部导管需拍胸片确认位置。不推荐抗生素或抗菌封管剂预防感染 置管部位优先顺序为右颈内静脉、股静脉、左颈内静脉;建议用12F导管,长度为右颈内静脉12 cm,股静脉≥24 cm,左颈内静脉20 cm。有出血风险患者不推荐肝素封管,也不建议用乙醇封管预防感染 3岁以下优先选择右颈内静脉;3岁以上可考虑右颈内静脉或股静脉。强调应确保导管/静脉直径比<0.33
抗凝策略 非高出血风险人群,间断RRT推荐肝素抗凝;无禁忌时CRRT首选枸橼酸抗凝。HIT时应避免肝素,改用阿加曲班或Ⅹa因子抑制剂 高出血风险者CRRT首选RCA而非无抗凝;IHD抗凝暂无明确推荐。 推荐RCA,但缺乏RCT证据;高出血风险人群暂无明确推荐
撤机标准 肾功能恢复或已无RRT治疗指征时可停机。不建议使用利尿剂促进肾功能恢复、减少疗程或频率 强调每日评估撤机可能,尿量为核心指标,停机后第2天尿量<100 ml提示撤机失败;条件允许时撤机后可过渡至IHD 同成人,但IHD撤机标准无明确推荐
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