Abstract
Acute renal failure (ARF) is a frequent complication in patients with multiple organ failure and sepsis leading to a significant increase of mortality in these critically ill patients (50– 70%). While for years, ARF was considered an unavoidable complication of multiple organ failure and thus not essential for the progress, various studies in recent years have shown an independent and fundamental influence of ARF and therefore its therapy on the survival of the patient.
In the late 1970s continuous forms of treatment were introduced into the intensive care units. The first form of this treatment option was continuous arteriovenous hemofiltration (CAVH), primarily developed for the treatment of overhydrated patients resistant to diuretics. Using pump driven forms of the treatment, such as venovenous hemofiltration or venovenous dialysis (CVVHD), nearly all patients can be treated sufficiently. CAVH in the early 1980s rarely exceeded a daily hemofiltrate of 8–15 L, while more recent randomized studies have shown that CVVH should be performed with an exchange amount of at least 35 ml/kg/h, which corresponds to a daily exchange of 60–80 L.
With the abandonment of arterial puncture and the use of specialized equipment including CVVH machines, allowing a distinct balance in these critically ill, the most important disadvantages of the formerly used CAVH are eliminated but have also led to a loss of simplicity of the method.
Scientific work in the next decade should focus on (local) anticoagulation and determination of the optimal amounts of hemofiltrate for different diseases.
Zusammenfassung
Das akute Nierenversagen (ANV) in der Intensivmedizin ist heute immer Teil eines Multiorganversagens (MOV). Seine Prognose ist mit einer Letalität von 50–70% weiterhin schlecht. Während jahrelang das ANV als möglicherweise unvermeidbare Komplikation des MOV hingenommen und für die Prognose als nicht wegweisend eingeschätzt wurde, zeigen verschiedene Untersuchungen der letzten Jahre einen unabhängigen, fundamentalen Einfluss des ANV und damit vor allem seiner Therapie auf das Überleben der Patienten. Dabei gehören die Ende der 1970iger Jahre in die Behandlung eingeführten kontinuierlichen Therapieoptionen heute neben der intermittierenden Dialyse auf den Intensivstationen zur Standardtherapie.
Das erste kontinuierliche Nierenersatzverfahren, die kontinuierliche arterio-venöse Hämofiltration (CAVH), war ursprünglich für die Behandlung therapierefraktärer Entwässerung bei Patienten mit renaler und kardialer Insuffizienz entwickelt worden und war für die Behandlung von MOV-Patienten unzureichend. Mit den pumpenunterstützten Behandlungsverfahren wie der kontinuierlichen veno-venösen Hämofiltration (CVVH) oder Dialyse (CVVHD) sind Therapieoptionen geschaffen worden, die jeden Patienten ausreichend effektiv behandeln können. Betrug die ursprüngliche tägliche Austauschmenge 8–15 L, haben randomisierte Untersuchungen gezeigt, dass die Patienten mit MOV und ANV bei Einsatz der CVVH von einem Austauschvolumen von mindestens 35 ml/kgKG/h profitieren, was einem täglichen Filtratumsatz von 60–80 L entspricht.
Mit dem Verzicht auf eine arterielle Punktion und der Nutzung hochtechnisierter Maschinen, die parallel zur Behandlung die Bilanzierung der Behandlung ermöglichen, sind die wesentlichen Nachteile der ursprünglichen CAVH mittlerweile beseitigt, wenn auch die kontinuierliche Therapie hierdurch ihre Einfachheit verloren hat.
Gegenstand der Forschung der nächsten Jahre werden die Untersuchungen zur (lokalen) Antikoagulation und zur differenzierten Betrachtung unterschiedlicher Austauschvolumina für verschiedene Patientengruppen sein.
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Kierdorf, H.P. Kontinuierliche Nierenersatztherapie in der Behandlung des akuten Nierenversagens: Geschichte und Entwicklung. Intensivmed 45, 194–204 (2008). https://doi.org/10.1007/s00390-008-0881-3
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DOI: https://doi.org/10.1007/s00390-008-0881-3