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Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51(11/12): 690-696
DOI: 10.1055/s-0042-101445
Fachwissen: Topthema
Anästhesiologie / Intensivmedizin
© Georg Thieme Verlag Stuttgart · New York

Akute Nierenschädigung - Ischämische Fernpräkonditionierung: ein Therapiekonzept für die Niere?

Acute kidney injury – remote ischaemic preconditioning: a nephroprotective strategy?
Melanie Meersch
,
Alexander Zarbock
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Publication History

Publication Date:
24 November 2016 (online)

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Die akute Nierenschädigung ist eine häufige und schwerwiegende Komplikation, die mit einer erhöhten Morbidität und Mortalität einhergeht. Sepsis und große chirurgische Eingriffe, insbesondere herzchirurgische Operationen, sind die häufigsten Ursachen für die Entwicklung einer akuten Nierenschädigung. Bereits geringgradige Serumkreatininwert-Erhöhungen sind mit einer erhöhten Mortalitätsrate assoziiert, sodass effektive Strategien zur Verhinderung einer akuten Nierenschädigung essenziell sind. Die ischämische Fernpräkonditionierung ist eine Intervention, die gekennzeichnet ist durch kurze Ischämie- und Reperfusionsphasen eines entfernten Gewebes oder Organs, bevor der eigentliche Schaden am Zielorgan stattfindet. Diese einfache und komplikationslose Maßnahme ist möglicherweise ein renoprotektiver Ansatz.

Abstract

Acute kidney injury is a common and serious complication with a huge impact on morbidity and short- as well as long-term mortality. Sepsis and major surgeries, especially cardiac surgery, are the most common causes of acute kidney injury. Slight increases of serum-creatinine levels are associated with adverse outcomes highlighting the relevance of the need for nephroprotective strategies to reduce the occurrence of acute kidney injury. Remote ischaemic preconditioning is an intervention consisting of brief episodes of ischaemia and reperfusion at a remote site before subsequent ischaemic insults occur. This simple and uncomplicated method may offer an effective nephroprotective strategy.

Kernaussagen

  • Die akute Nierenschädigung (acute kidney injury, AKI) ist eine häufige Komplikation, die mit einer erhöhten Mortalitätsrate einhergeht.

  • Im Rahmen der Nephroprotektion empfehlen die KDIGO-Leitlinien

    • die Herstellung eines ausreichenden Perfusionsdrucks,

    • den restriktiven Umgang mit nephrotoxischen Substanzen,

    • die Vermeidung von Hyperglykämien und

    • eine engmaschige Überwachung der sog. „klassischen“ Biomarker Serumkreatinin und Urinvolumen.

  • Die ischämische Fernpräkonditionierung (remote ischaemic preconditioning, RIPC) ist eine einfache und komplikationsarme Intervention, die gekennzeichnet ist durch eine Abfolge kurzer Episoden einer Ischämie und Reperfusion an einem entfernten Gewebe oder Organ.

  • Metaanalysen konnten zeigen, dass RIPC einen renoprotektiven Effekt besitzt.

  • Eine aktuelle Studie bei Hochrisikopatienten nach herzchirurgischen Eingriffen zeigte eine Reduktion der AKI um 15 % und eine Milderung des Schweregrads der AKI durch die präoperative Anwendung von RIPC.

  • Folgender Mechanismus wird postuliert: Durch die kurzen Ischämie- und Reperfusionsphasen werden proinflammatorische Zytokine freigesetzt, die bestimmte Rezeptoren an den renalen Tubulusepithelzellen aktivieren, sodass es zu einem kurzfristigen Zellzyklusarrest kommt, der die Tubulusepithelzellen vor weiteren Schäden schützt.

  • Propofol scheint den protektiven Mechanismus von RIPC aufzuheben.

  • Eine generelle Empfehlung zur RIPC kann aufgrund der uneinheitlichen Ergebnisse der aktuellen großen Studien nicht gegeben werden.

  • Bei Hochrisikopatienten für die Entwicklung einer AKI sollte eine Intervention mit RIPC erwogen werden.

Schlüsselwörter:

akute Nierenschädigung - Nephroprotektion - ischämische Fernpräkonditionierung

Keywords:

acute kidney injury - nephroprotection - remote ischaemic preconditioning
 

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