Skip to main content
SpringerLink
Log in

Akutes Nierenversagen bei Sepsis

Epidemiologie, Diagnose, Therapie

Acute renal failure in septic patients

Epidemiology, diagnosis and therapy

  • Leitthema
  • Published:
Intensivmedizin und Notfallmedizin

Zusammenfassung

Das akute Nierenversagen stellt ein für die Prognose des septischen Patienten entscheidendes Organversagen dar. Neue Vorstellungen in der Pathophysiologie sowie klarere neue Definitionen sollen in der Zukunft zu besseren Behandlungsoptionen führen. Derzeit sind das frühzeitige Erkennen, die rasche zielgerichtete Kreislauftherapie mit kristalloiden Lösungen und Vasopressoren sowie das Vermeiden nephrotoxischer Substanzen die wichtigsten Bausteine der Prävention und Therapie. Ist eine Nierenersatztherapie notwendig, sollte diese frühzeitig nach Intensivaufnahme begonnen werden. Unterschiedliche Verfahren mit verschiedenen Vor- und Nachteilen stehen zur Verfügung, die im Sinne einer Differenzialtherapie eingesetzt werden sollten. Eine ausreichende Dosis des Nierenersatzes ist wichtig, jedoch scheinen nach neueren Studien weitere Steigerungen der Dosis nicht mit einer weiteren Verbesserung des „Outcomes“ verbunden zu sein.

Abstract

Acute renal failure has a major impact on the prognosis of septic patients. Changes in the understanding of the pathophysiology and more precise definitions of acute kidney injury (AKI) are expected to lead to improved therapeutic options in the future. At present early recognition, early targeted fluid therapy with crystalloids and vasopressors, as well as the avoidance of nephrotoxic substances are the key measures in prevention and therapy of AKI. If renal replacement therapy (RRT) becomes necessary it should be started promptly following ICU admission. Different modalities of RRT with various advantages and disadvantages are available and should be applied differentially. While a sufficient dose of RRT is important, new studies suggest that further dose increases do not lead to improved outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2

Literatur

  1. Lassnigg A, Schmidlin D, Mouhieddine M et al (2004) Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 15:1597–1605

    Article  CAS  PubMed  Google Scholar 

  2. Metnitz PG, Krenn CG, Steltzer H et al (2002) Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 30:2051–2058

    Article  PubMed  Google Scholar 

  3. Oppert M, Engel C, Brunkhorst FM et al (2008) Acute renal failure in patients with severe sepsis and septic shock-a significant independent risk factor for mortality: results from the German Prevalence Study. Nephrol Dial Transplant 23:904–909

    Article  PubMed  Google Scholar 

  4. Joannidis M, Metnitz PG (2005) Epidemiology and natural history of acute renal failure in the ICU. Crit Care Clin 21:239–249

    Article  PubMed  Google Scholar 

  5. Liangos O, Wald R, O’Bell JW et al (2006) Epidemiology and outcomes of acute renal failure in hospitalized patients: a national survey. J Am Soc Nephrol 1:43–51

    Google Scholar 

  6. Bagshaw SM, George C, Dinu I, Bellomo R (2008) A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant 23:1203–1210

    Article  PubMed  Google Scholar 

  7. John S, Eckardt KU (2007) Renal replacement strategies in the ICU. Chest 132:1379–1388

    Article  PubMed  Google Scholar 

  8. Schrier RW, Wang W (2004) Acute renal failure and sepsis. N Engl J Med 351:159–169

    Article  CAS  PubMed  Google Scholar 

  9. Oppert M et al (2008) Impact of the development of acute kidney injury (AKI) on outcome of patients with severe sepsis and septic shock – Results from the visep trial. Intensive Care Med 34(Suppl 1):247

    Google Scholar 

  10. Wan L, Bagshaw SM, Langenberg C (2008) Pathophysiology of septic acute kidney injury: What do we really know? Crit Care Med 36(Suppl):S198–S203

    Article  PubMed  Google Scholar 

  11. Kellum JA (1997) The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence. Crit Care 1:53–59

    Article  PubMed  Google Scholar 

  12. Ho KM, Sheridan DJ (2006) Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ 333:420

    Article  CAS  PubMed  Google Scholar 

  13. Rivers E, Nguyen B, Havstad S et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377

    Article  CAS  PubMed  Google Scholar 

  14. Lin SM, Huang CD, Lin HC et al (2006) A modified goal-directed protocol improves clinical outcomes in intensive care unit patients with septic shock: a randomized controlled trial. Shock 26:551–557

    Article  PubMed  Google Scholar 

  15. Brunkhorst FM, Engel C, Bloos F et al (2008) Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358:125–139

    Article  CAS  PubMed  Google Scholar 

  16. Bourgoin A, Leone M, Delmas A et al (2005) Increasing mean arterial pressure in patients with septic shock: effects on oxygen variables and renal function. Crit Care Med 33:780–786

    Article  CAS  PubMed  Google Scholar 

  17. Martin C, Viviand X, Leone M, Thirion X (2000) Effect of norepinephrine on the outcome of septic shock. Crit Care Med 28:2758–2765

    Article  CAS  PubMed  Google Scholar 

  18. Friedrich JO, Adhikari N, Herridge MS, Beyene J (2005) Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 142:510–524

    CAS  PubMed  Google Scholar 

  19. Gattinoni L, Brazzi L, Pelosi P (1995) A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med 333:1025–1033

    Article  CAS  PubMed  Google Scholar 

  20. Follath F, Cleland JG, Just H et al (2002) Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study): a randomised double-blind trial. Lancet 360:196–202

    Article  CAS  PubMed  Google Scholar 

  21. Piccinni P, Dan M, Barbacini S et al (2006) Early isovolaemic haemofiltration in oliguric patients with septic shock. Intensive Care Med 32:80–86

    Article  CAS  PubMed  Google Scholar 

  22. Ronco C, Bellomo R, Homel P et al (2000) Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 356:26–30

    Article  CAS  PubMed  Google Scholar 

  23. Bouman CSC, Oudemans-van Straaten HM, Tijssen JGP et al (2002) Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med 30:2205–2211

    Article  PubMed  Google Scholar 

  24. Bagshaw SM, Uchino S, Bellomo R (2009) Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care 24:129–140

    Article  PubMed  Google Scholar 

  25. Kellum JA, Angus DC, Johnson JP et al (2002) Continuous versus intermittent renal replacement therapy: a meta-analysis. Intensive Care Med 28:29–37

    Article  PubMed  Google Scholar 

  26. Vinsonneau C, Camus C, Combes A et al (2006) Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 368:379–385

    Article  PubMed  Google Scholar 

  27. John S, Griesbach D, Baumgartel M et al (2001) Effects of continuous haemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Nephrol Dial Transplant 16:320–327

    Article  CAS  PubMed  Google Scholar 

  28. Oudemans-van Straaten HM, Bosmann RJ, Koopmans M et al (2009) Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med 37:545–552

    Article  Google Scholar 

  29. Palevsky PM, Zhang JH, O’Connor TZ et al (2008) Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359:7–20

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité-Universitätsmedizin Berlin, Berlin, Deutschland

    M. Oppert

  2. Medizinische Klinik 4, Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Deutschland

    S. John

Authors
  1. M. Oppert
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. John
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. John.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Oppert, M., John, S. Akutes Nierenversagen bei Sepsis. Intensivmed 46, 549–556 (2009). https://doi.org/10.1007/s00390-009-0111-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00390-009-0111-7

Schlüsselwörter

Keywords

Search

Navigation