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Nierenersatztherapie in der Intensivmedizin

„Klassische“ Verfahren

Renal replacement therapy in intensive care

“Classical” procedures

  • Leitthema
  • Published:
Der Nephrologe Aims and scope

Zusammenfassung

Das akute Nierenversagen (ANV) in der Intensivmedizin tritt heute ausschließlich als Teil eines Multiorganversagens (MOV) auf, die Letalität liegt zwischen 50 und 70% . Neben der intermittierenden Hämodialyse sind kontinuierliche Nierenersatzverfahren in die Behandlung des ANV eingeführt worden, die heute auf vielen Intensivstationen zum Standardtherapierepertoire gehören. Wesentliche Vorteile dieser Verfahren im Vergleich zur intermittierenden Hämodialyse sind eine verbesserte hämodynamische Stabilität, die Vermeidung von schnellen Elektrolyt- und Wasserverschiebungen bei einfacher Flüssigkeitsbilanzierung und eine an die Bedürfnisse der Patienten angepasste Ernährung. Ihr wesentlicher Nachteil ist die kontinuierliche Antikoagulation. Bei ausreichenden Austauschvolumina können kontinuierliche Verfahren die Azotämie mindestens so gut kontrollieren wie die intermittierende Dialyse. Bei der kontinuierlichen Hämofiltration sollte die Austauschmenge 35 ml/kg KG/h betragen, eine Dosis, die wahrscheinlich auf die kontinuierlichen Dialyseverfahren übertragen werden kann. Eine intermittierende Dialyse beim kritisch Kranken muss täglich erfolgen. Allgemeiner Konsens ist, dass schwer Kranke und insbesondere MOV-Patienten mit Sepsis eher mit einem kontinuierlichen Therapieverfahren behandelt werden sollten. Außerdem gibt es Hinweise, dass die extrakorporale Therapie frühzeitig erfolgen sollte, um einen zusätzlich negativen Effekt des ANV auf andere Vitalfunktionen zu vermeiden.

Abstract

Acute renal failure (ARF) in the intensive care unit is always part of multiple organ failure (MOF) with a mortality between 50% and 70%.

The ARF patient can be treated by intermittent dialysis and, since the end of the 1970s, with continuous forms of extracorporeal treatment. The main advantages of continuous renal replacement therapy as opposed to intermittent hemodialysis are greater hemodynamic stability, avoidance of rapid fluid and electrolyte shift with easier fluid management, and nutrition without restriction. The uninterrupted necessity for anticoagulants is the most important disadvantage. In each form of treatment, an adequate dosage for each critically ill patient is needed. Intermittent dialysis is necessary daily und in continuous hemofiltration the exchange volume should reach 35 ml/kg/h. Very critically ill MOF patients, especially those with accompanying sepsis or septic shock, should receive continuous forms of treatment. Treatment should be started early as it is necessary to avoid further damage to other vital functions due to loss of exocrine renal function via fluid retention.

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Kierdorf, H.P. Nierenersatztherapie in der Intensivmedizin. Nephrologe 1, 88–96 (2006). https://doi.org/10.1007/s11560-006-0019-1

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