Zusammenfassung
Eine Einschränkung der Nierenfunktion bei Patienten mit akut dekompensierter Herzinsuffizienz (ADHI) ist relativ häufig. Außerdem tritt bei mehr als 70% aller Patienten mit akuter Herzinsuffizienz im Verlauf ein Anstieg der Kreatininkonzentration auf. Wesentliche Ursache der unter dem Terminus kardiorenales Syndrom zusammengefassten Situation sind hämodynamische Veränderungen, Volumenveränderungen, die Aktivierung des Renin-Angiotensin-Aldosteron-Systems sowie des sympathischen Nervensystems. Die resultierende Retention von Wasser und Natrium sowie die generelle Vasokonstriktion führen zu einer renalen Minderdurchblutung sowie zu einer sich teilweise rasch entwickelnden Diuretikaresistenz, was den Einsatz extrakorporaler Nierenersatzverfahren sinnvoll machen kann. Gleiches gilt für die Situation der ADHI. In der Intensivmedizin wird in diesen Fällen v. a. die kontinuierliche Nierenersatztherapie mit gutem klinischem Erfolg eingesetzt. Alternativ besteht auch die Möglichkeit einer reinen Ultrafiltration mittels miniaturisierter extrakorporaler Systeme. Die Peritonealdialyse wird bei ADHI eher selten eingesetzt. Alle extrakorporalen Maßnahmen haben aufgrund ihrer Invasivität nicht unerhebliche Risiken. Deshalb sollte die extrakorporale Therapie der ADHI spezifischen Situationen wie der ausgeprägten Diuretikaresistenz oder dem gleichzeitigen Vorliegen eines oligurischen oder anurischen akuten Nierenversagens vorbehalten bleiben.
Abstract
Renal insufficiency is common in patients with acute coronary insufficiency (ACI) and is proven to be an independent risk factor for these patients. In addition, more than 70% of patients with ACI will develop an increased creatinine concentration. The main reasons for this so-called cardio-renal syndrome (CRS) are changes in hemodynamics, volume depletion, and the activation of the renin-aldosterone-angiotensin and the sympathetic nervous systems. The resulting retention of sodium and water as well as the general vasoconstriction results in renal hypoperfusion and diuretic resistance. In such cases, the use of extracorporeal renal replacement therapy may be useful. The same is true for patients with ACI (e.g., with cardiogenic shock) and acute renal failure. In the intensive care unit, nearly all these patients are treated successfully with continuous extracorporeal replacement therapy. In some cases according to the clinical situation, the use of miniaturized systems for pure ultrafiltration can be considered. Peritoneal dialysis used for patients with chronic heart and kidney failure is rarely used in the critically ill with ACI. Due to the invasiveness of the treatment, it must be taken into account that all forms of extracorporeal treatment have potential risks. Therefore, due to current data these extracorporeal techniques should be reserved for patients with ACI and diuretic resistance or accompanying acute renal failure.
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Kierdorf, H. Einsatz von Nierenersatzverfahren bei akut dekompensierter Herzinsuffizienz. Intensivmed 46, 421–428 (2009). https://doi.org/10.1007/s00390-009-0083-7
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DOI: https://doi.org/10.1007/s00390-009-0083-7
Schlüsselwörter
- Akut dekompensierte Herzinsuffizienz
- Akutes Nierenversagen
- Kardiorenales Syndrom
- Ultrafiltration
- Kontinuierliche Nierenersatztherapie