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Nierenersatztherapie

Unterschiedliche Verfahren und Differenzialindikationen

Renal replacement therapy

Different techniques and differential indications

  • Leitthema
  • Published:
Intensivmedizin und Notfallmedizin

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.

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  1. Medizinische Klinik mit Schwerpunkt Nephrologie und internistische Intensivmedizin, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland

    A. Jörres

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Jörres, A. Nierenersatztherapie. Intensivmed 47, 422–428 (2010). https://doi.org/10.1007/s00390-010-0174-5

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