Munuaisvaurio (akuutti)
Käypä hoito -suositus |  Julkaistu: 2014-01-21   | Tila: voimassa  |  Aihepiiri(t): Nefrologia
Mikä on Käypä hoito -suositus?
Suomalaisen Lääkäriseuran Duodecimin, Suomen Anestesiologiyhdistyksen, Tehohoitolääketieteen alajaoksen ja Suomen Nefrologiyhdistyksen asettama työryhmä
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Munuaisvaurio (akuutti)

Käypä hoito
21.1.2014
Suomalaisen Lääkäriseuran Duodecimin, Suomen Anestesiologiyhdistyksen, Tehohoitolääketieteen alajaoksen ja Suomen Nefrologiyhdistyksen asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Muut suositukset

Miten viitata Käypä hoito -suositukseen? «»1

Keskeinen sisältö

  • Aikuisten akuutti munuaisvaurio (Acute Kidney Injury, AKI) on yleistyvä ongelma.
  • Akuutin munuaisvaurion riskiä suurentavat korkea ikä, diabetes, yleinen ateroskleroosi, useat lääkehoidot sekä röntgenvarjoaineet, sepsis, rabdomyolyysi, kuivuminen tai verenvuoto, sydämen vajaatoiminta, miessukupuoli ja munuaisten lieväkin krooninen vajaatoiminta.
  • Hoidossa keskeisintä ovat riskipotilaiden löytäminen, AKI:n tunnistaminen varhain, lääkityksiin, varjoaineisiin ja kuivumiseen liittyvän munuaisvaurion ehkäiseminen, riittävä nestehoito elektrolyyttiliuoksella sekä verenpaineen normaalistaminen. Lisäksi on huomioitava rabdomyolyysin ja myrkytysten (erityisesti sienet ja alkoholit) mahdollisuus ja suljettava pois virtsan kulkuesteet.
  • Riskipotilaalta tulee ennen munuaistoksisten lääkkeiden aloitusta määrittää laskennallinen glomerulusten suodatusnopeus (Glomerular Filtration Rate, GFR), ja se tulee myös tarkistaa lääkkeiden käytön aloituksen ja annosten suurentamisen jälkeen.
  • AKI:ssä on tauotettava sitä aiheuttavat tai pahentavat lääkkeet ja arvioitava munuaisten vajaatoiminnassa kertyvien lääkkeiden annokset.
  • Potentiaalisti munuaistoksisia aineita ovat tulehduskipulääkkeet, ACE:n estäjät, ATR:n salpaajat, vankomysiini, aminoglykosidit, spironolaktoni ja hydroksietyylitärkkelysliuokset.
  • Metformiinia tulee välttää munuaisten vajaatoiminnassa, sillä se kumuloituu, mikä suurentaa maitohappoasidoosin riskiä.
  • Varjoainevaurion ehkäisyyn nesteytyksellä tulee kiinnittää erityistä huomiota.
  • Lääkkeistä (esim. dopamiinista, mannitolista tai furosemidista) ei ole hyötyä AKI:n ehkäisyssä eikä hoidossa. Toisaalta nestekuorma lisää kuolleisuutta, joten furosemidia voidaan harkinnanvaraisesti käyttää purkamaan ylimääräistä nestekuormaa, kun AKI on lievä tai paranemisvaiheessa. Ensisijaisesti furosemidin käyttö on rajattu potilaisiin, joilla ei ole AKI:tä.
  • Laajat kontrolloidut tutkimukset vahvistavat, että korvaushoidon annoksen suurentaminen yli 22 ml/kg/h:aan ei paranna potilaan ennustetta. Erittäin suuriannoksinen hoito voi sepsiksessä olla jopa haitallinen. Korvaushoidon varhaisemman aloituksen ja filtraation lisäämisen hyödyt ovat molemmat epävarmat.
  • Akuutti munuaisvaurio huonontaa lievänäkin itsenäisesti potilaan ennustetta. Sen pitkäaikaisennuste on myös varsin huono ja hoidon kustannukset suuret.

Aiheen rajaus

  • Suosituksessa ei käsitellä lasten tai raskaana olevien naisten AKI:tä eikä munuaisten kroonista vajaatoimintaa. Suosituksen ulkopuolelle jäävät myös akuutit nefriitit ja yleissairaudet, kuten vaskuliitit ja myyräkuume.

Tavoitteet ja kohderyhmät

  • Suosituksen tavoitteena on lisätä koko terveydenhuoltohenkilöstön tietoa AKI:stä, sen riskitekijöistä ja ennusteesta sekä kuvata AKI:n ehkäisykeinot ja keskeinen hoito. Kaikkien päivystyksessä työskentelevien lääkärien ja sairaalalääkärien on tärkeää hallita vaikean sairaalahoitoa vaativan AKI:n tunnistaminen ja alkuhoito.

Määritelmä ja luokittelu

Taulukko 1. Akuutin munuaisvaurion KDIGO-luokittelukriteerit (joko kreatiniini- tai virtsamääräkriteeri) «Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Inter, 2012 Suppl 1-138»1.
Luokka Kreatiniinikriteeri Virtsamääräkriteeri
1 S-Krean suureneminen > 26,5 µmol/l 48 h:n aikana tai 1,5–1,9-kertainen suureneminen perustasosta edellisten 7 vrk:n aikana < 0,5 ml/kg/h 6–12 tunnin ajan
2 S-Krean 2,0–2,9 kertainen suureneminen < 0,5 ml/kg/h ≥ 12 tunnin ajan
3 S-Krean > 3,0 kertainen suureneminen perustasosta
S-Krea > 354 µmol/l tai munuaisten korvaushoito
< 0,3 ml/kg/h ≥ 24 tunnin ajan tai anuria ≥ 12 tunnin ajan

Ilmaantuvuus ja etiologia

Kliininen kulku ja ennuste

Ennustetekijät

Taulukko 2. Kuolemanvaaran ennustetekijät akuutissa munuaisvauriossa.
Cox-malli Riskisuhde 95 %:n luottamusvälit
Ikä (kymmentä vuotta kohden) 1,13 1,01–1,26
Sepsis 1,87 1,33–2,63
Aivo-oire 4,58 3,30–6,35
Maksan vajaatoiminta 1,90 1,34–2,71
Hematologinen oire 1,46 1,01–2,10
Dialyysi 1,79 1,21–2,66

Toteaminen

Altistavat tekijät ja ehkäisy

Varjoaineet

ACE:n estäjät, ATR:n salpaajat ja mineralokortikoidireseptoriantagonistit

Tulehduskipulääkkeet

Metformiini

  • Metformiini kumuloituu munuaisten vajaatoiminnassa.
  • Maitohappoasidoosiriskin takia metformiinin käyttö on vasta-aiheinen, jos GFR on alle 60 ml/min.
  • Nestehukan ja varjoainetutkimuksen yhteydessä metformiini tulee tauottaa.
  • Ks. lisätietoja Käypä hoito -suosituksesta Diabetes, kohta Hyperglykemian hoito «Diabetes»6.

Antibiootit

Rabdomyolyysi

  • Rabdomyolyysi on vakava tila, joka hoitamattomana voi johtaa neste- ja elektrolyyttitasapainon vakavaan häiriöön ja jopa kuolemaan.
  • Hoidetun taudin ennuste on hyvä ja mahdollinen munuaisvaurio yleensä ohimenevä.
  • Potilaan ensiapuun kuuluvat hypovolemian mahdollisimman nopea korjaaminen elektrolyyttiliuoksella ja virtsan alkalisointi natriumbikarbonaatilla.

Sepsis

  • Sepsis on tärkein AKI:lle altistavista sairauksista. Ks. lisätietoja Käypä hoito -suosituksesta Sepsis «Sepsis (aikuiset)»7.

Kuivuminen ja verenvuoto

Tuumorilyysioireyhtymä

Kohonnut vatsaontelonsisäinen paine

Akuutin munuaisvaurion hoito

Lääkehoito

Nestehoito

Munuaisten korvaushoidot

Jaksoittainen vai jatkuva hoito?

Hoidon intensiteetti ja aloitusajankohta

Filtraation lisääminen dialyysihoitoon ja korvausnesteen annostelu

  • Hemofiltraation lisääminen dialyysihoitoon ei ilmeisesti vähennä kuolleisuutta AKI:ssä «Hemofiltraation lisääminen munuaiskorvaushoitoon ei ilmeisesti vähennä kuolleisuutta akuutissa munuaisvauriossa.»C.
  • Filtraatiohoitojen yhteydessä annosteltava korvausneste voidaan annostella joko ennen suodatinta (filtteriä) (= prediluutio) tai sen jälkeen (= postdiluutio). Suomessa on yleisesti käytössä prediluutio, jonka hyötynä ovat suodattimen pienemmät tukkeutumisongelmat ja käyttöiän piteneminen. Haittapuolena on, että osa annetusta korvausnesteestä suodattuu, mikä heikentää hoidon tehoa. Luotettava näyttö pre- tai postdiluution paremmuudesta puuttuu.

Munuaisten kroonisen vajaatoiminnan akuutti vaikeutuminen

  • Ei ole tutkimusnäyttöä siitä, pitäisikö munuaisten kroonisen vajaatoiminnan akuutti vaikeutuminen hoitaa eri tavalla kuin AKI muuten.

Ravitsemus

Suomalaisen Lääkäriseuran Duodecimin, Suomen Anestesiologiyhdistyksen, Tehohoitolääketieteen alajaoksen ja Suomen Nefrologiyhdistyksen asettama työryhmä

Munuaisvaurio (akuutti) -suosituksen historiatiedot «Munuaisvaurio (akuutti), Käypä hoito -suosituksen historiatiedot»3.

Puheenjohtaja:

Ville Pettilä, dosentti, tehohoidon ylilääkäri; HYKS

Jäsenet:

Annika Laukkanen, LT, erikoislääkäri; HYKS, tehohoito, ATEK (kokoava kirjoittaja)

Mikko Haapio, LL, osastonlääkäri; HYKS, medisiininen tulosyksikkö, nefrologian klinikka

Leena Halme, LKT, dosentti, osastonylilääkäri; HYKS, vatsaelinkirurgian klinikka

Merja Hanski, LL, yleislääketieteen erikoislääkäri; Nokian terveyskeskuksen sairaala

Marja Puurunen, LKT, kardiologian erikoislääkäri; SPR Veripalvelu, Käypä hoito -toimittaja

Ari Uusaro, LKT, dosentti; KYS, tehohoidon klinikka

Maarit Wuorela, LT, osastonylilääkäri; Turun kaupungin hyvinvointitoimiala, erikoissairaanhoito

Sidonnaisuudet:

Mikko Haapio:Asiantuntijapalkkio (Kustannus Oy Duodecim), luentopalkkioita (Abbott, Amgen, Fresenius Medical Care Suomi, Novartis, Roche), koulutus- tai kongressikuluja yrityksen tuella (B. Braun Avitum, Fresenius Medical Care Suomi, MSD, Roche)

Leena Halme: Asiantuntijapalkkio (Duodecim/Gastroenterologiakirja), lisenssitulo tai tekijänpalkkio (Duodecim/Gastroenterologiakirja)

Merja Hanski: Ei sidonnaisuuksia

Annika Laukkanen: Koulutus- tai kongressikuluja yrityksen tuella (Fresenius Kabi, Pfizer)

Ville Pettilä: Ei sidonnaisuuksia

Marja Puurunen: Luentopalkkioita (Sanofi-Aventis, Bayer, Boehringer Ingelheim)

Ari Uusaro: Ei sidonnaisuuksia

Maarit Wuorela: Ei sidonnaisuuksia

Kirjallisuusviite

Munuaisvaurio (akuutti) (online). Suomalaisen Lääkäriseuran Duodecimin, Suomen Anestesiologiyhdistyksen, Tehohoitolääketieteen alajaoksen ja Suomen Nefrologiyhdistyksen asettama työryhmä. Helsinki: Suomalainen Lääkäriseura Duodecim, 2014 (viitattu pp.kk.vvvv). Saatavilla internetissä: www.kaypahoito.fi

Tarkemmat viittausohjeet: «http://www.kaypahoito.fi/web/kh/viittaaminen»2

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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