Zusammenfassung
Traditionell wird eine renale Dysfunktion bei kardialer Insuffizienz (kardiorenales Syndrom Typ 1) auf ein sog. Vorwärtsversagen zurückgeführt. Hierbei induziert eine verminderte kardiale Auswurfleistung bzw. ein erniedrigter mittlerer arterieller Druck eine komplexe neurohumorale Aktivierung, die zu einem erhöhten renalen Gefäßwiderstand und schließlich zu einer renalen Funktionsverminderung führt.
Im letzten Jahrzehnt haben mehrere Studien gezeigt, dass das Ausmaß der renalen Dysfunktion weniger mit Parametern des Vorwärtsversagen (kadialer Index, mittlerer arterieller Druck) korreliert, als vielmehr mit Stauungsindikatoren, wie dem linksventrikulären enddiastolischen Druck oder dem zentralen Venendruck (ZVD), also Parametern eines Rückwärtsversagens. Der Einfluss eines Rückwärtsversagen auf die Nierenfunktion ist jedoch keineswegs, wie häufig nahegelegt, nur auf die Erhöhung des ZVD als renaler Drainagedruck beschränkt, sondern umfasst ein breites Spektrum von Mechanismen: Beteiligt sind die Organsysteme rechtes Herz, Lunge, Leber, der Darm mit seinen proinflammatorischen Signalen, aber auch andere Faktoren, wie das renale interstitielle Ödem (sog. renales Kompartmentsyndrom) oder der intraabdominelle Druck.
Als therapeutische Konsequenz geht es um eine an die individuelle Situation des Patienten orientierte Modulation des „Preloads“, um an verschiedenen Segmenten des Tubulus ansetzende Diuretika inklusive Aldosteron- und ADH-Antagonisten, eine extrakorporale Flüssigkeitselimination mittels Ultrafiltration oder die Peritonealdialyse.
Abstract
Traditionally, renal dysfunction in congestive heart failure (cardiorenal syndrome type 1) has been attributed to reduced cardiac output and low mean arterial perfusion pressure, which elicit a series of neurohumoral activations resulting in increased renal vascular resistance and decreased renal function.
During the last decade, several studies have shown that the extent of renal dysfunction is not so closely associated with indices of forward failure—such as the cardiac index or mean arterial pressure—but rather with indicators of congestion, such as left ventricular enddiasystolic pressure or central venous pressure (CVP), which are indicators of backward failure. The impact of backward failure on renal function is not confined to an elevation of CVP, the renal drainage pressure, but includes a broad spectrum of mechanisms. Involved are the organ systems right heart, lung, the liver, the proinflammatory signals originating from the intestines, but also renal interstitial edema (renal compartment syndrome) and the intraabdominal pressure.
The therapeutic measures must focus on the modulation of the preload adapted to the specific situation of an individual patient. This includes diuretics aiming at different segments of the tubulus system including antagonists of aldosteron and ADH, extracorporeal fluid elimination by ultrafiltration or peritoneal dialysis.
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Interessenkonflikt. W. Druml gibt an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Druml, W. Nierenversagen bei Herzinsuffizienz und Hypervolämie. Med Klin Intensivmed Notfmed 109, 252–256 (2014). https://doi.org/10.1007/s00063-013-0323-2
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DOI: https://doi.org/10.1007/s00063-013-0323-2