Anästhesiol Intensivmed Notfallmed Schmerzther 2018; 53(02): 150-157
DOI: 10.1055/s-0043-110038
Fortbildung
Georg Thieme Verlag KG Stuttgart · New York

Nierenersatzverfahren bei akuter Nierenschädigung – Indikation und Durchführung

Renal Replacement Therapy in Acute Kidney Injury – Indication and Implementation
Mira Küllmar
,
Alexander Zarbock
Further Information

Publication History

Publication Date:
09 February 2018 (online)

Zusammenfassung

Die akute Nierenschädigung ist eine häufige Komplikation kritisch kranker Patienten auf Intensivstationen, die mit einer hohen Morbidität und Letalität einhergeht [1]. Sie ist ein unabhängiger Risikofaktor für ein verschlechtertes Outcome kritisch kranker Patienten [2]. Diese Übersichtsarbeit fasst die verfügbare Evidenz für die Indikation und den Einsatz von Nierenersatzverfahren bei akuter Nierenschädigung anhand aktueller Literatur zusammen.

Abstract

Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with a worse short- and long-term outcome. The KDIGO (Kidney Disease: Improving Global Outcomes) guidelines suggest to implement preventive strategies in high-risk patients. Definition and classification of acute kidney injury according to the KDIGO criteria are based on an increase in serum creatinine and/or a decrease in urinary output. Renal replacement therapy (RRT) is the only supportive measure in patients with severe AKI. The KDIGO guidelines recommend to initiate RRT immediately if an absolute indication exists. However, in the absence of absolute indication, there are no recommendations when to start RRT in AKI patients with a progressive decline of renal function. Continuous or intermittent techniques of renal replacement therapy may be used equally for treatment of acute kidney injury. In hemodynamically instable patients and patients with increased intracranial pressures continuous renal replacement therapy is recommended. Although weak evidence exists, regional citrate anticoagulation is suggested for patients receiving continuous renal replacement therapy and systemic heparin anticoagulation is suggested for patients receiving intermittent renal replacement therapy. The KDIGO guidelines recommend to deliver an effluent volume of 20 – 25 ml/kg/h for CRRT in AKI.

Kernaussagen
  • Die akute Nierenschädigung ist ein unabhängiger Prädiktor für das Outcome kritisch kranker Patienten auf Intensivstationen.

  • Zur Prävention bei Risikopatienten sollten konsequent die KDIGO-Leitlinien angewendet werden.

  • Die KDIGO-Kriterien als Diagnosehilfe definieren die Stadien der akuten Nierenschädigung anhand des Anstiegs des Serum-Kreatinins und/oder der Verringerung der Urinausscheidung.

  • Die Indikationen für ein Nierenersatzverfahren werden anhand absoluter Kriterien gestellt. Andererseits besteht jedoch kein Konsens über den Zeitpunkt des Beginns dieser Therapie vor Eintreten der absoluten Indikation.

  • Zur Therapie der akuten Nierenschädigung können intermittierende oder kontinuierliche Verfahren genutzt werden. Belege für den Vor- oder Nachteil der einen oder anderen Behandlungsform gibt es bisher nicht.

  • Bei hämodynamisch instabilen Patienten und bei Patienten mit erhöhtem intrakraniellen Druck sollte ein kontinuierliches Verfahren gewählt werden.

  • Für intermittierende Verfahren wird Heparin zur Antikoagulation empfohlen, für kontinuierliche Verfahren Zitrat. Jedoch gibt es für diese Empfehlung keine gute Evidenz. Ausnahmen stellen Patienten mit erhöhtem Blutungsrisiko, mit Leberversagen oder mit HIT Typ II dar.

  • Für kontinuierliche Verfahren wird ein Austauschvolumen von 20 – 25 ml/kgKG/h empfohlen.

  • Der Gefäßzugang der ersten Wahl ist die rechte V. jugularis interna.

 
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