Summary
More than 60% of patients with chronic renal failure also have cardiovascular diseases, and they therefore are in need of invasive diagnostic procedures and in many cases heart surgery. Patients with known moderate renal insufficiency have a high risk of severe complications and mortality after heart surgery. In order to prevent the deterioration of renal function (acute renal failure, ARF) after coronary angiography or heart surgery, many approaches have been tested. Both effective and ineffective procedures are discussed in this review. The effective procedures include: 1) increased oral fluid intake and infusion of normal saline solution (target CVP: 8–12 mmHg), 2) sufficient oxygenation (target HCT >30%), if necessary tranfusion of red cells already before intervention, 3) N-acetylcysteine (ACC) 2–4×600 mg orally, first intake 2 hours before intervention, 4) continue aspirin until the day of surgery/intervention and restart aspirin within 24–48 hours post surgery, 5) in case of preexisting renal insufficiency (S.-creat.: >2.0 mg/dl, creat.cl. <60 ml/min) hemofiltration (exchange volumen 1 l/h) or bicarbonate-hemodialysis starting immediately after intervention/surgery. In contrast to these effective renoprotective procedures, loop diuretics such as furosemide are detrimental and renal-dose dopamine as well as the dopamine-receptor agonist fenoldopam are ineffective. The antioxidant ascorbic acid as compared to ACC only provides a marginal beneficial effect in preventing contrast-induced nephropathy. Taken together, the most important nephroprotective procedures are volume supplementation and oxygenation starting already 4–6 hours before intervention. In patients with known renal insufficiency (S.-creat. >2.0 mg/dl) volume status is best controlled when hemofiltration or bicarbonate hemodialysis are applied.
Zusammenfassung
Patienten mit chronischer Niereninsuffizienz haben zu mehr als 60% auch kardiovaskuläre Erkrankungen, die einer invasiven Diagnostik und Therapie bedürfen. Patienten mit vorbestehender Niereninsuffizienz haben nach herzchirurgischen Operationen ein deutlich erhöhtes Komplikations- und Mortalitätsrisiko. Zur Prävention eines postinterventionellen Nierenversagens (ANV) nach Koronarangiographie und Koronarchirurgie wurden zahlreiche Therapieansätze untersucht, die in dieser Arbeit diskutiert werden. Zu den effektiven Ansätzen in Bezug auf Vermeidung eines ANV und Verbesserung des Überlebens zählen: 1) intensivierte Volumengabe oral plus Infusion von isotoner Kochsalzlösung (Ziel ZVD 8–12 mmHg), 2) ausreichende Oxygenierung (Ziel-HKT >30%), eventuell schon Transfusion vor der Intervention, 3) N-Acetylcystein (ACC) 2- bis 4-mal 600 mg oral, 1. Einnahme 2 h vor der Intervention, 4) Acetylsalicylsäure (ASS) prä-OP nicht absetzen, rascher Wiederbeginn post-OP innerhalb von 24 bis 48 h nach Intervention, 5) bei vorbestehender stärkerer Niereninsuffizienz (S.-Creat.: >2,0 mg/dl, Creat.-Cl. <60 ml/min) Hämofiltration (Austauschvolumen 1 l/h) oder Bicarbonatdialyse, Beginn direkt nach Intervention. Dagegen haben sich Schleifendiuretika als schädlich, Dopamin in „Nierendosis“ und auch der Dopaminrezeptor- Agonist Fenoldopam als ineffektiv zur Nephroprotektion herausgestellt. Ascorbinsäure (Vitamin C) als Antioxidans hat im Vergleich zu ACC einen nur marginalen protektiven Effekt in der Vermeidung der kontrastmittelinduzierten Nephropathie. Wichtigste nephroprotektive Maßnahmen sind eine ausreichende Hydratation und Oxygenierung bereits vor der Angiographie oder Operation, bei vorbestehender Niereninsuffizienz (S.-Creat. >2,0 mg/dl) ist die periinterventionelle Volumensteuerung durch Hämofiltration oder Bicarbonatdialyse vorteilhaft.
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Lonnemann, G. „Optimale“ Vorbereitung des nierenkranken Patienten auf die Herzoperation. Clin Res Cardiol Suppl 2 (Suppl 1), S39–S45 (2007). https://doi.org/10.1007/s11789-006-0036-7
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DOI: https://doi.org/10.1007/s11789-006-0036-7
Key words
- Heart surgery
- acute renal failure
- chronic renal failure
- nephroprotection
- co-morbidity
- mortality
- volume status
- hemodialysis
- aspirin
- N-acetylcysteine