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Nierenersatzverfahren auf der Intensivstation

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Renal replacement therapy in the intensive care unit

Current aspects

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Zusammenfassung

Das akute Nierenversagen (ANV) ist eine häufige Komplikation in der Intensivmedizin. Die Inzidenz des ANV ist steigend, die Letalität unverändert hoch. In Europa haben sich zur Therapie des ANV die kontinuierlichen Hämofiltrationsverfahren („continuous renal replacement therapy“, CRRT) mit einem Behandlungsanteil von 80% durchgesetzt. Der Vorteil der CRRT liegt insbesondere bei Patienten im Multiorganversagen in einer größeren Kreislaufstabilität und besseren Volumensteuerung als bei der klassischen Hämodialyse („intermittend hemodialysis“, IHD). Ob die CRRT der IHD bezüglich der Letalität auf der „intensive care unit“ (ICU) oder im Krankenhaus überlegen ist, ist bislang unklar. Untersuchungen aus dem Jahr 2000 zeigten, dass die Letalität bei nichtseptisch bedingtem ANV bei einer initialen Filtrationsdosierung von 35 ml/h×kgKG am niedrigsten ist. Ein aktueller Ansatz ist die langsame kontinuierliche Dialyse („slow extended daily dialysis“, SLEDD), die die Vorteile der CRRT mit denen der IHD verbindet. Auch hier ist eine Verbesserung des Outcomes bislang nicht belegt. Eine abschließende, evidenzbasierte Empfehlung zur Dosierung der CRRT oder eine definitive Antwort auf die Frage, ob eine tägliche IHD sinnvoller ist als eine CRRT, wird wahrscheinlich erst nach Abschluss zweier laufender, multizentrischer Studien möglich sein [VA/NIH Acute Renal Failure Trial Network (ATN) Study sowie Augmented Versus Normal Renal Replacement Therapy in Severe Acute Renal Failure Study (ANZICS 2005) Australia and New Zealand Intensive Care Group].

Abstract

Acute renal failure is a common complication in intensive care medicine. While the incidence of acute renal failure increases, mortality still remains at a high level. In Europe continuous renal replacement therapy (CRRT) has become the standard treatment for acute renal failure. Continuous renal replacement therapy has the advantage of achieving a more stable haemodynamic situation and an easier volume management compared to intermittent haemodialysis (IHD). Until now there has been no evidence to suggest that either classical IHD or CRRT is superior in reducing mortality. Using CRRT in patients with acute renal failure, an ultrafiltration rate adjusted to the patient’s bodyweight at 35 ml/kg×h is recommended. A new approach in renal replacement therapy is the slow extended daily dialysis (SLEDD), which combines the advantages of CRRT and IHD. First results are promising, but further investigations are needed to show whether outcome can be improved. A final evidence-based recommendation on the dosing of CRRT or a definitive answer to the question whether daily IHD is better than CRRT, can probably only be possible after two running multicentre studies, the VA/NIH Acute Renal Failure Trial Network (ATN) study and the Augmented Versus Normal Renal Replacement Therapy in Severe Acute Renal Failure Study (ANZICS 2005) Australia and New Zealand Intensive Care Group.

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  1. Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum der Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt a.M., Deutschland

    T.M. Bingold, B. Scheller & H. Wissing

  2. Klinik für Anästhesiologie, Ludwig-Maximilians-Universität München, München, Deutschland

    B. Zwissler

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  1. T.M. Bingold
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Correspondence to T.M. Bingold.

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Bingold, T., Scheller, B., Zwissler, B. et al. Nierenersatzverfahren auf der Intensivstation. Anaesthesist 56, 1105–1114 (2007). https://doi.org/10.1007/s00101-007-1279-5

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