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Niereninsuffizienz bei Patienten mit Leberinsuffizienz

Renal insufficiency in patients with hepatic insufficiency

  • Intensivmedizin
  • Published:
Wiener klinisches Magazin Aims and scope

Zusammenfassung

Hintergrund

Eine Niereninsuffizienz kann bei etwa 20 % aller hospitalisierten Patienten mit fortgeschrittener Leberzirrhose beobachtet werden. Die Hälfte der Patienten mit dekompensierter Leberzirrhose entwickelt innerhalb von 14 Monaten eine Einschränkung der Nierenfunktion. Als Ursache findet sich bei etwa einem Drittel der Patienten ein intrarenaler, bei 2 Dritteln ein prärenaler Auslöser. Bereits geringgradige Veränderungen der Nierenfunktion gehen mit einer Verschlechterung der Prognose einher. Bei etwa einem Drittel der Patienten mit prärenaler Ursache kann durch eine adäquate Volumentherapie­ keine Besserung der Nierenfunktion erzielt werden. Dieses funktionelle Nierenversagen wird als hepatorenales Syndrom (HRS) bezeichnet.

Pathophysiologie

Die Pathophysiologie­ des HRS beruht auf einer Abnahme des effektiven­ Blutvolumens durch zunehmende Vasodilation im Splanchnikusgebiet. Durch Zunahme­ der Herzauswurfleistung kann dies initial­ noch ausgeglichen werden. In der Folge kommt es zu einer Abnahme des effektiven Blutvolumens, die über die Stimulierung der Barorezeptoren zu einer Aktivierung vasopressorischer Systeme mit konsekutiver renaler Vasokonstriktion führt. Zusätzlich kommt es durch Aktivierung des hepatorenalen Reflexes zu einer weiteren renalen Vaso­konstriktion.

Therapie

Die derzeit am besten untersuchte und effektivste Therapie besteht in der Gabe von Terlipressin in Kombination mit Humanalbumin. Dadurch kann das HRS bei bis zu 50 % der Patienten erfolgreich behandelt werden. Die Langzeitprognose ist durch die Schwere der Lebererkrankung definiert. Ein Langzeitüberleben ist nur durch eine Lebertransplantation möglich.

Abstract

Background

Renal dysfunction is a common complication of cirrhosis, occurring in approximately 20 % of all hospitalized patients with cirrhosis and associated with increased mortality. In about two thirds of the patients, renal dysfunction is caused by prerenal disorders (e.g. gastrointestinal bleeding, diuretics, bacterial infection); one third is caused by intrarenal diseases (e.g. hepatitis associated glomerulonephritis). In most patients, prerenal failure can be successfully handled by volume therapy. In one third, volume replacement is not effective any more to improve kidney function. This kind of prerenal failure is called hepatorenal syndrome (HRS).

Pathophysiology

The pathophysiology is based on an increased splanchic vasodilation, which cannot be compensated any more by an increased cardiac output. Therefore, patients with cardiac insufficiency are more at risk of developing HRS. The decompensation leads to a stimulation of the baroreceptors with consecutive activation of the sympathetic nerve system, the renin–angiotensin–aldosteron system (RAAS), and nonosmotic release of vasopressin. This results in renal vasoconstriction, which is strengthened by the activation of hepatorenal reflex secondary to an increase in intrahepatic pressure and/or decrease in sinusoidal blood flow.

Therapy

Several studies have shown that the vasopressin analogue terlipressin combined with albumin can reverse HRS in up to 50 % of patients. Long-term survival can only be achieved by liver transplantation. Improving kidney function before transplantation improves outcome after transplantation.

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Authors and Affiliations

  1. Abteilung Innere Medizin und Intensivmedizin, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Österreich

    K. Lenz, M. Binder, R. Buder, A. Gruber, B. Gutschreiter & M. Voglmayr

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  1. K. Lenz
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  2. M. Binder
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Correspondence to K. Lenz.

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Interessenkonflikt

K. Lenz, M. Binder, R. Buder, A. Gruber, B. Gutschreiter und M. Voglmayr geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Additional information

Dieser Beitrag wurde in der Zeitschrift Medizinische Klinik Intensivmedizin Notfallmedizin 2014 · 109:240–245, DOI 10.1007/s00063-013-0322-3 erstveröffentlicht.

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Lenz, K., Binder, M., Buder, R. et al. Niereninsuffizienz bei Patienten mit Leberinsuffizienz. Wien klin Mag 17, 16–21 (2014). https://doi.org/10.1007/s00740-014-0018-1

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