Organersatzverfahren: Update Nierenersatztherapie

Zusammenfassung

Die steigende Inzidenz der schweren akuten Nierenschädigung in Verbindung mit weiterhin hohen Mortalitätsraten stellt die intensivmedizinische Versorgung vor eine wachsende Herausforderung. Nierenersatzverfahren sind die wichtigste Therapiemaßnahme und kommen gleichermaßen zunehmend zum Einsatz – ungeachtet dessen werden wesentliche Aspekte ihrer Umsetzung infolge einer eingeschränkten Evidenzlage kontrovers diskutiert.

Abstract

Renal replacement therapy (RRT) remains the cornerstone of treatment for severe acute kidney injury. However, despite its spreading use along with rising incidences of acute kidney injury, evidence of most recommendations is limited so far. Early initiation of RRT seems to reduce mortality but is associated with higher incidence of adverse events. Continuous RRT is advantageous in terms of hemodynamic control and decreased incidence of chronic dialysis dependency but without affecting mortality. Regional citrate anticoagulation should be preferred with regard to longer filter circuit life span. Intensified RRT with a prescribed dose ≥ 35 mL/kg/h has no benefit with regard to mortality but is associated with higher occurrence of complications. Urine output has the best prognostic value for cessation of RRT. Biomarkers of renal impairment and recovery are needed for better guidance of therapy.

Kernaussagen

• Infolge der steigenden Inzidenz der schweren akuten Nierenschädigung (KDIGO-Stadium 3) werden Nierenersatzverfahren immer häufiger eingesetzt.

• Die Evidenzlage vieler Empfehlungen zum Umgang mit Nierenersatzverfahren ist gering.

• Der frühzeitige Beginn eines Nierenersatzverfahrens senkt möglicherweise die Mortalität – bei steigender Komplikationsrate.

• Bei vergleichbarer Mortalitätsrate senken kontinuierliche Nierenersatzverfahren möglicherweise die Inzidenz chronischer Dialysepflichtigkeit gegenüber intermittierenden Dialyseverfahren.

• Die Anlage von Dialysekathetern in die Vv. subclaviae sollte soweit möglich vermieden werden.

• Regionale Citrat-Antikoagulation verlängert die Filterlaufzeit ohne nachweisbaren Vorteil hinsichtlich der Mortalität.

• Intensivierte Ablaufdosen sollten bei höherer Komplikationsrate und gleicher Mortalität vermieden werden.

• Zur Evaluation der Beendigung der Nierenersatztherapie sollte die Urinausscheidung verwendet werden.

Schlüsselwörter

akute Nierenschädigung - Nierenersatzverfahren - Leitlinien - regionale Citrat-Antikoagulation

Key words

acute kidney injury - renal replacement therapy - guidelines - regional citrate anticoagulation

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