Überwässerung und Dialyse beim akuten Nierenversagen

Zusammenfassung

Patienten mit einem dialysepflichtigen akuten Nierenversagen haben trotz aller Fortschritte der Intensivmedizin weiterhin eine sehr hohe Krankenhausletalität. Je nach Patientenkollektiv liegt diese bei bis zu 80 %. Mehrere Beobachtungsstudien konnten einen Zusammenhang zwischen Flüssigkeitsüberladung und Mortalität nachweisen. Durch die Überwässerung mit konsekutivem Organödem wird die Perfusion und damit die Sauerstoffversorgung und Substratbereitstellung für die Zellen erschwert. Das führt zu weiterer Nierenschädigung. Darüber hinaus verringert die Überwässerung die Serumkreatininkonzentration (Dilution bei Vergrößerung des Extrazellularraums) und verschleiert damit die Diagnose des akuten Nierenversagens. Dies führt zu einer verspäteten Einleitung nephroprotektiver Maßnahmen, was eine weitere Aggravierung des Nierenschadens bedingt. Dieser Nierenschaden führt dann im weiteren Verlauf zu einer Verschlechterung der Prognose. In dem vorliegenden Review diskutieren wir die Auswirkungen der Überwässerung auf die Prognose anhand der aktuellen Literatur bewerten sowie Kriterien für die Indikation zur Nierenersatztherapie.

Abstract

Despite the advances in critical care medicine, the hospital mortality in patients with acute kidney injury (AKI) requiring dialysis remains high. Depending on the underlying disease the in-house mortality is reported to be up to 80 %. Several observational studies demonstrated an association between mortality and fluid overload. A primary mechanism of interest is that fluid overload causes tissue edema and subsequent reduction of perfusion, oxygenation and nutrient delivery. This results in further renal damage. In addition, fluid overload-related dilution within the extracellular space causes artificially low serum creatinine, which masks AKI diagnosis. As a consequence, renal protective management strategies are deferred, which further aggravates kidney injury. This aggravation of renal damage subsequently increases the mortality. This review discusses the role of fluid overload for outcomes in critically ill patients as described in the current literature and assesses criteria for the initiation of renal replacement therapy in this critically ill population.

Schlüsselwörter

Dialyse - akutes Nierenversagen - Sepsis - Zeitpunkt der Dialysebehandlung

Keywords

dialysis - acute kidney injury - sepsis - timing of dialysis

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