Zusammenfassung
Für die Behandlung des akuten Nierenversagens steht mit den kontinuierlichen oder intermittierenden Verfahren der Hämodialyse, Hämofiltration oder Hämodiafiltration eine Vielzahl von extrakorporalen Behandlungsmodalitäten zur Verfügung. Auf der Basis der vorliegenden klinischen Studien bringt keines der Verfahren einen generellen Vorteil bezüglich Patientenüberleben oder renaler Erholung mit sich. Die primäre Therapiewahl sollte sich daher an der konkreten klinischen Situation des Patienten orientieren. Wesentliche Aspekte hierbei sind die hämodynamische Situation, der Flüssigkeitshaushalt, das Blutungsrisiko sowie die gewünschte Patientenmobilität. Im Verlauf der Behandlung kann sich hier der Fokus verändern und eine Modifikation oder ein Wechsel des Verfahrens sinnvoll sein. Bei kritisch Kranken mit akutem Nierenversagen bietet sich oftmals eine Initialtherapie mit einem kontinuierlichen Verfahren an, das nach Stabilisierung der Kreislaufverhältnisse und klinischer Besserung auf ein diskontinuierliches Verfahren mit der Möglichkeit der besseren Mobilisierung des Patienten umgestellt werden kann. Falls nur intermittierende Verfahren verfügbar sind, kann auch mit diesen eine effektive und sichere Behandlung des instabilen Patienten durchgeführt werden, vorausgesetzt, adäquate Maßnahmen zum Volumenmanagement werden ergriffen. Hingegen kann der Einsatz extrakorporaler Nierenersatzverfahren mit der Indikation der adjunktiven Therapie bei Sepsis und Schock auf Basis der bisherigen klinischen Daten nicht für den generellen Einsatz außerhalb kontrollierter Studien empfohlen werden.
Abstract
A variety of extracorporeal techniques are available for the treatment of acute kidney injury, including continuous or intermittent hemodialysis, hemofiltration, or hemodiafiltration. On the basis of current evidence, the initial choice of renal replacement therapy (RRT) modality does not have an impact on different outcomes, such as patient survival or renal recovery. Thus, this decision should be made based on the specific clinical situation and according to the course of the patient’s treatment. Among the key aspects are the hemodynamic situation, hydration status, risk of bleeding complications, and desired patient mobility. The focus may change during the course of treatment and eventually require a modification of RRT or a switch between treatment modalities. In critically ill patients with acute kidney failure, the practical approach might be to use continuous RRT for the early treatment of hemodynamic instability, followed by sustained low-efficiency dialysis (SLED) or intermittent hemodialysis (IHD) when intensive care can be stepped down but kidney function has not yet recovered. However, present data suggest that if only IHD is available, this may also constitute a viable treatment option in hemodynamically unstable patients, provided that optimized strategies for volume management are in place. The use of extracorporeal blood purification techniques with the sole indication of adjunctive sepsis therapy can presently not be recommended except during controlled clinical studies.
Literatur
Augustine JJ, Sandy D, Seifert TH, Paganini EP (2004) A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 44:1000–1007
Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R (2008) Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med 36:610–617
Bell M, Granath F, Schon S et al (2007) Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Intensive Care Med 33:773–780
Boldt J, Menges T, Wollbruck M et al (1994) Continuous hemofiltration and platelet function in critically ill patients. Crit Care Med 22:1155–1160
Cole L, Bellomo R, Hart G et al (2002) A phase II randomized, controlled trial of continuous hemofiltration in sepsis. Crit Care Med 30:100–106
Cruz DN, Antonelli M, Fumagalli R et al (2009) Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 301:2445–2452
De Vriese AS, Colardyn FA, Philippe JJ et al (1999) Cytokine removal during continuous hemofiltration in septic patients. J Am Soc Nephrol 10:846–853
De Vriese AS, Vanholder RC, Pascual M et al (1999) Can inflammatory cytokines be removed efficiently by continuous renal replacement therapies? Intensive Care Med 25:903–910
Fliser D, Kielstein JT (2004) A single-pass batch dialysis system: an ideal dialysis method for the patient in intensive care with acute renal failure. Curr Opin Crit Care 10:483–488
Fliser D, Kielstein JT (2006) Technology insight: treatment of renal failure in the intensive care unit with extended dialysis. Nat Clin Pract Nephrol 2:32–39
Gastaldello K, Melot C, Kahn RJ et al (2000) Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study. Nephrol Dial Transplant 15:224–230
Honore PM, Jamez J, Wauthier M et al (2000) Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med 28:3581–3587
Kellum JA, Song M, Venkataraman R (2004) Hemoadsorption removes tumor necrosis factor, interleukin-6, and interleukin-10, reduces nuclear factor-kappaB DNA binding, and improves short-term survival in lethal endotoxemia. Crit Care Med 32:801–805
Kielstein JT, Kretschmer U, Ernst T et al (2004) Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: a randomized controlled study. Am J Kidney Dis 43:342–349
Kumar VA, Craig M, Depner TA, Yeun JY (2000) Extended daily dialysis: a new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis 36:294–300
Lameire N, Van Biesen W, Vanholder R (2005) Acute renal failure. Lancet 365:417–430
Lins RL, Elseviers MM, Van der Niepen P et al (2009) Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial. Nephrol Dial Transplant 24:512–518
Lonnemann G, Floege J, Kliem V et al (2000) Extended daily veno-venous high-flux haemodialysis in patients with acute renal failure and multiple organ dysfunction syndrome using a single path batch dialysis system. Nephrol Dial Transplant 15:1189–1193
Marshall MR, Golper TA, Shaver MJ et al (2001) Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int 60:777–785
Marshall MR, Golper TA, Shaver MJ et al (2002) Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy. Am J Kidney Dis 39:556–570
Mehta RL, McDonald B, Gabbai FB et al (2001) A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 60:1154–1163
Morgera S, Haase M, Kuss T et al (2006) Pilot study on the effects of high cutoff hemofiltration on the need for norepinephrine in septic patients with acute renal failure. Crit Care Med 34:2099–2104
Mulder J, Tan HK, Bellomo R, Silvester W (2003) Platelet loss across the hemofilter during continuous hemofiltration. Int J Artif Organs 26:906–912
Oudemans-Van Straaten HM, Bosman RJ, Spoel JI van der, Zandstra DF (1999) Outcome of critically ill patients treated with intermittent high- volume haemofiltration: a prospective cohort analysis. Intensive Care Med 25:814–821
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
Pannu N, Klarenbach S, Wiebe N et al (2008) Renal replacement therapy in patients with acute renal failure: a systematic review. JAMA 299:793–805
Passadakis PS, Oreopoulos DG (2007) Peritoneal dialysis in patients with acute renal failure. Adv Perit Dial 23:7–16
Payen D, Mateo J, Cavaillon JM et al (2009) Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med 37:803–810
Phu NH, Hien TT, Mai NT et al (2002) Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. N Engl J Med 347:895–902
Rabindranath K, Adams J, MacLeod AM, Muirhead N (2007) Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev CD003773
Ratanarat R, Brendolan A, Piccinni P et al (2005) Pulse high-volume haemofiltration for treatment of severe sepsis: effects on hemodynamics and survival. Crit Care 9:R294–R302
Ronco C, Brendolan A, Lonnemann G et al (2002) A pilot study of coupled plasma filtration with adsorption in septic shock. Crit Care Med 30:1250–1255
Saudan P, Niederberger M, De Seigneux S et al (2006) Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 70:1312–1317
Schefold JC, Haehling S von, Corsepius M et al (2007) A novel selective extracorporeal intervention in sepsis: immunoadsorption of endotoxin, interleukin 6, and complement-activating product 5a. Shock 28:418–425
Strazdins V, Watson AR, Harvey B (2004) Renal replacement therapy for acute renal failure in children: European guidelines. Pediatr Nephrol 19:199–207
Uchino S, Bellomo R, Kellum JA et al (2007) Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury. Int J Artif Organs 30:281–292
Uehlinger DE, Jakob SM, Ferrari P et al (2005) Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 20:1630–1637
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
Winchester JF, Harbord N, Tyagi P, Rosen H (2009) Extracorporeal removal of drugs and toxins. In: Jörres A, Ronco R, Kellum JA (Hrsg) Management of acute kidney problems. Springer, Berlin Heidelberg New York Tokyo
Interessenkonflikt
Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Jörres, A. Nierenersatztherapie. Intensivmed 47, 422–428 (2010). https://doi.org/10.1007/s00390-010-0174-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00390-010-0174-5