Das akute Nierenversagen – Intensivmedizinische Aspekte

Das akute Nierenversagen ist charakterisiert durch die Abnahme der Nierenfunktion über Stunden oder Tage, was immer zur Retention harnpflichtiger Substanzen, häufig auch zur Störung der Elektrolythomöostase und zur Abnahme der Urinausscheidung führt. Es kann die Folge prä-, post- und intrarenaler Störungen sein, wobei die Grenzen häufig unscharf sind. Im Vergleich zur Allgemeinbevölkerung ist die Inzidenz des akuten Nierenversagens durch die Kumulation schädigender Ereignisse bei hospitalisierten Patienten, besonders auf Intensivstationen, erhöht. Bei diesen Patienten ist die Ursache häufig extrarenal, z. B. bei einer Sepsis mit Multiorganversagen, als Folge einer Minderperfusion oder nach der Applikation nephrotoxischer Medikamente. Die frühe Diagnose und das rasche Beheben der potenziellen Ursachen sind wichtig für die Prognose der Patienten, da ein protrahierter und höhergradiger Nieren-Funktions-Verlust direkt mit einer erhöhten Morbidität und Mortalität einhergeht. Aufgrund der unterschiedlichen und z. T. unverstandenen Ursachen des Nierenversagens gibt es keine einheitliche Therapie für das akute Nierenversagen, dafür aber verschiedene supportive Maßnahmen bis hin zur Nierenersatztherapie, die, wenn sie notwendig wird, früh sowie in einer ausreichenden Dosis und Biokompatibilität erfolgen muss. Entscheidend ist der Versuch, die Nephrotoxizität der medizinischen Maßnahmen zu minimieren und ein akutes Nierenversagen zu verhindern. Bei dem größten Teil der Patienten ohne vorbestehende Niereninsuffizienz kann im Verlauf eine Restitution der Nierenfunktion erreicht werden. Ein erhöhtes Risiko für das Entwickeln einer chronischen Niereninsuffizienz bleibt bei diesen Patienten aber bestehen.

Acute kidney injury (AKI) is characterized by a rapid decline of renal function within hours or days, generally associated with azotaemia, electrolyte disorders and decreased urinary output. It might be caused by pre-renal, intrinsic or post-renal disorders or a combination of these. In comparison to the outpatient population, AKI is more common in hospitalized and especially in critically ill patients, due to the accumulation of multiple disorders that can affect the kidney. In these patients, it is most frequently secondary to extrarenal events such as sepsis with multi-organ damage, a result of decreased organ perfusion or application of nephrotoxic drugs. The early detection and elimination of the cause or trigger for the acute renal failure is of utmost importance for the patient outcome, as a longer and more severe loss of renal function is directly associated with an increased mortality and long term morbidity. Because of the multitude of the renal disturbances which are not yet completely understood, there is no specific therapy for the acute kidney injury, but multiple supportive measures including renal replacement therapy. In cases where such a therapy is needed, it has to be provided early in the course of AKI and sufficient in dose and biocompatibility. Nevertheless, it is most important to try to minimize nephrotoxicity of medical measures and interventions in order to prevent the development of kidney injury. Most patients without chronic kidney disease in their history who survive their acute illness typically recover to dialysis independency and a sufficient renal function. However, they are at an increased risk for the subsequent development of chronic renal failure.

Key words

acute kidney injury - critical illness - renal replacement therapy - sepsis - acute tubular necrosis

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