Intensivmedizin und Notfallmedizin

, Volume 43, Issue 3, pp 175–188 | Cite as

Sepsis und Akutes Nierenversagen

Nephroprotektion und Einsatz von Nierenersatzverfahren
ÜBERSICHT
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Zusammenfassung

Das akute Nierenversagen (ANV) ist eine häufige Komplikation der Sepsis, die den Verlauf entscheidend beeinflusst. Mehr als die Hälfte der Patienten mit septischem Schock weisen ein ANV auf und noch bei 20% aller Patienten mit moderater Sepsis, ist ein solches nachzuweisen. Septische Patienten mit ANV weisen eine signifikant höhere Letalität, als diejenigen Patienten mit ANV ohne Sepsis auf (70 vs. 45%). Während jahrelang das ANV als möglicherweise unvermeidbare Komplikation des septischen Multiorganversagens hingenommen und für die Prognose als nicht wegweisend eingeschätzt wurde, zeigen verschiedene Untersuchungen der letzten Jahre einen unabhängigen, fundamentalen Einfluss des ANV auf das Überleben der Patienten. Pathophysiologisch besteht eine enge Verzahnung zwischen den Mediatoren, die im Rahmen des Sepsissyndroms eine wesentliche Rolle spielen und lokalen, intrarenalen Prozessen. Interventionen zur Nephroprotektion und Prophylaxe eines ANV beruhen im Wesentlichen auf einer Beeinflussung der renalen Hämodynamik. Hierzu gehört vor allem eine Verbesserung der allgemeinen Nierenperfusion Nach ausreichender Volumenexpansion ist gerade beim septischen Patienten der Einsatz von Vasokonstriktoren erforderlich, welche durch die Steigerung des peripheren Widerstandes, trotz der potenziellen Nebenwirkungen an der Niere zu einem positiven Effekt führen. Wesentliche Substanz in diesem Zusammenhang ist das Noradrenalin. Selektive Therapieansätze, meist hervorragend pathophysiologisch begründet, welche die lokale Imbalanz zwischen Vasodilatation und Vasokonstriktion beeinflussen sollen, waren für die bisher untersuchten Substanzen, wie z. B. ANP oder Endothelin-Rezeptorantagonisten nicht erfolgreich. Eine Modulation intrarenaler Vorgänge gelingt möglicherweise mit N-Acetylcystein, während niedrig dosiertes Dopamin zur Prophylaxe des ANV heute obsolet ist. Schleifendiuretika können bei wenigen Patienten die Diurese beeinflussen, sind potenziell nephrotoxisch und haben keinen Einfluss auf das ANV. Für die extrakorporale Therapie des septischen ANV stehen die intermittierende Dialyse und kontinuierliche Therapieverfahren wie die CVVH zur Verfügung. Es gilt der allgemeine Konsensus, dass aufgrund der Schwere der Gesamterkrankung der Patienten diese eher mit einem kontinuierlichen Therapieverfahren behandelt werden sollten. Die Therapie dieser Patienten sollte frühzeitig erfolgen, um einen zusätzlich negativen Effekt des ANV auf andere Vitalfunktionen zu vermeiden. Bei Nutzung der CVVH ist ein Austauschvolumen von mindestens 35 ml/kg/h anzustreben. Ein Einsatz kontinuierlicher Nierenersatztherapie bei fehlendem ANV zur Elimination von Mediatoren, ist zum jetzigen Zeitpunkt nicht zu empfehlen.

Schlüsselwörter

Akutes Nierenversagen Sepsis kontinuierliche Nierenersatztherapie Nephroprotektion 

Sepsis and acute renal failure: nephroprotection and continuous renal replacement therapy

Summary

Acute renal failure (ARF) is a frequent complication in patients with sepsis leading to a significant increase of mortality in these critically ill as compared with ARF patients without sepsis (70 vs 45%). In cases with septic shock more than half of the patients develop ARF. In previous years the development of ARF in multiple organ failure seemed to be fated and was not relevant for the prognosis of the patients. However, this could be by refuted by different studies. Therefore, the protection from ARF in early phases of sepsis seems to be promising. Interventions to protect the kidney against ARF can be roughly divided into two main strategies. The first is optimizing general renal perfusion by volume load and the application of vasopressors (e. g. norepinephrine) despite theoretical side effects of this substance on kidneys in healthy individuals. The second is the selective modulation, e. g. of intrarenal imbalance between vasoconstriction and vasodilatation and of other mechanisms involved in ARF, i. e. formation of free oxygen radicals, inflammation, tubular cast formation. Unfortunately, neither the application of ANP nor endothelin receptor antagonists were successful. A promising substance is N-acetylcysteine, proven to prevent contrast media associated nephropathy in some cases. Dopamine in “renal dosage” should be avoided. Furosemide produces diuresis in a few patients, is potentially nephrotoxic and has no influence on the outcome of ARF. Septic patient with ARF can be treated by intermittent hemodialysis and continuous forms of extracorporeal treatment, e. g. CVVH. Due to the severity of the disease, continuous forms of the treatment should be favored in very critically ill. Treatment should be started early, as it is necessary to avoid further damage to other vital functions due to the loss of exocrine renal function via fluid retention. CVVH should be performed with an exchange of at least 35 ml/kg/h and should be reserved for ARF patients as there is no scientific evidence of a non-renal indication for continuous forms of treatment.

Key words

Acute renal failure sepsis continuous renal replacement therapy nephroprotection 
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© Steinkopff-Verlag 2006

Authors and Affiliations

  1. 1.Klinik für Nieren- und Hochdruckkrankheiten am Klinikum BraunschweigBraunschweigGermany

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