Zusammenfassung
Die Einführung kontinuierlicher Verfahren („continuous renal replacement therapy“, CRRT) revolutionierte den Einsatz der Nierenersatztherapie auf den Intensivstationen. Plötzlich waren ausgezeichnete hämodynamische Stabilität, praktisch unlimitierter Flüssigkeitsentzug und jederzeitiger Therapiebeginn möglich. Auch im Hinblick auf die Therapieintensität schienen mit den Geräten der neueren Generation kaum Grenzen nach oben hin gesetzt. Unter diesen Vorraussetzungen zeigten erste kleinere randomisierte Studien um die Jahrtausendwende einen Überlebensvorteil für eine CRRT-Dosis von mindestens 35 ml/kgKG/h bzw. für tägliche intermittierende Hämodialyse. Diese Effekte konnten in nachfolgenden großen multizentrischen Studien nicht bestätigt werden, sodass sich derzeitige Therapieempfehlungen in einem Bereich von 25–30 ml/kgKG/h effektiv verabreichter Dosis bzw. bei 2-tägiger intermittierender Hämodialyse bewegen. Trotz der besseren Verträglichkeit der kontinuierlichen Verfahren konnte bislang in keiner Studie ein Überlebensvorteil gegenüber den intermittierenden Verfahren schlüssig bewiesen werden. Aufgrund des steigenden Kostendrucks erleben modifizierte intermittierende Verfahren wie „sustained low-efficiency dialysis“ (SLED) bei verbesserter hämodynamischer Verträglichkeit eine Renaissance. Die regionale Antikoagulation mit Citrat befindet sich wegen der deutlich höheren Laufzeiten, geringerem Blutungsrisiko und besserer Biokompatibilität im raschen Vormarsch. Als bester früher Indikator für eine erfolgreiche Beendigung einer Nierenersatztherapie gilt derzeit das Wiedereinsetzen einer Spontandiurese von mehr als 450 ml/24 h.
Abstract
The development of continuous modalities (continuous renal replacement therapy, CRRT) revolutionized the use of renal replacement therapy for critically ill patients. Suddenly excellent hemodynamic stability, nearly unlimited fluid removal and unrestricted availability became feasible. Furthermore the newest generation CRRT machines allowed practically unlimited intensity of treatment. Under these conditions initial single centre small randomized controlled trials carried out at the turn of the millennium indicated improved survival by administering CRRT doses equal or above 35 ml/kg body weight/h or daily hemodialysis. These effects, however, could not be reproduced by subsequent large multicenter randomized controlled trials. Consequently current recommendations suggest 25–30 ml/kg body weight/h actually delivered dose in CRRT or alternate day intermittent hemodialysis. Despite better hemodynamic tolerability of CRRT no trials could prove substantially improved survival over intermittent hemodialysis. Consequently modified intermittent modalities, such as sustained low efficiency dialysis (SLED) show improved acceptance under the pressure of increasing cost constraints. Regional anticoagulation by citrate is on the rise due to increased system survival, reduced risk of bleeding and improved biocompatibility. A reoccurrence of spontaneous diuresis above 450 ml/24 h has been shown to be one of the most reliable early predictors for successful termination of RRT.
Abbreviations
- Q S :
-
Substitutionsrate
- Q B :
-
Blutfluss
- Q D :
-
Dialysatfluss
- S K :
-
Siebkoeffizient konvektiv
- S D :
-
Siebkoeffizient diffusiv
- Kprä :
-
Korrekturfaktor für Prädilution
- FF:
-
Filtrationsfraktion
- Hkt:
-
Hämatokrit
- CRRT:
-
kontinuierliche Nierenersatztherapie
- CVVH:
-
kontinuierliche venovenöse Hämofiltration
- CVVHD:
-
kontinuierliche venovenöse Hämodialyse
- CVVHDF:
-
kontinuierliche venovenöse Hämodiafiltration
- IHD:
-
intermittierende Hämodialyse
- SLED:
-
„sustained low efficiency dialysis“
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Interessenkonflikt
Der korrespondierende Autor weist auf folgende Beziehungen hin: Referentenhonorare von Gambro und Fresenius Medical Care.
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Joannidis, M. Nierenersatztherapie: Wann? Wie? Wie lange?. Intensivmed 48, 264–269 (2011). https://doi.org/10.1007/s00390-010-0236-8
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DOI: https://doi.org/10.1007/s00390-010-0236-8