Therapie des akuten Nierenversagens - Konzepte und Kontroversen

Zusammenfassung.

Die Therapie des prolongierten akuten Nierenversagens erfordert im Regelfall ein Nierenersatzverfahren. Hierzu stehen verschiedene extrakorporale Nierenersatzverfahren sowie die Peritonealdialyse zur Verfügung. Die extrakorporalen Nierenersatzverfahren werden auf Grund des angewandten physikalischen Prinzips der Toxinelimination in Hämodialyse (Diffusion) und Hämofiltration (Konvektion) eingeteilt. Außerdem ist zwischen intermittierenden und kontinuierlichen Verfahren zu unterscheiden. Unter dem Aspekt der Aktivierung des Immunsystems werden biokompatible und bioinkompatible Membranen unterschieden. Prospektiv-randomisierte Studien an großen Patientengruppen haben die auf Grund theoretischer Überlegungen vermuteten Vorteile spezieller Vorgehensweisen in wesentlichen Punkten nicht bestätigen können. Letalität, Dauer und Folgekomplikationen des akuten Nierenversagens werden durch Verwendung biokompatibler Membranen nicht gesenkt. Eine Überlegenheit kontinuierlicher Nierenersatzverfahren besteht nicht grundsätzlich, sondern lediglich bei hämodynamisch instabilen Patienten, bei denen sie eine optimale Steuerung des Flüssigkeitshaushaltes und damit des arteriellen Blutdruckes gewährleisten. Aufwendige Hämofiltrationstechniken zur Zytokinelimination können auf Grund mangelhafter Selektivität und des bisher fehlenden Nachweises eines klinischen Nutzens derzeit noch nicht empfohlen werden. Die Bedeutung der „Intensität” des Eliminationsverfahrens und der optimale Zeitpunkt des Therapiebeginns sind nicht hinreichend geklärt. Die Wahl des Nierenersatzverfahrens richtet sich nach klinischer Indikation (Kriterium: hämodynamische Situation), Praktikabilität (Kriterien: Verfügbarkeit des Gerätes und Schulung des Personals) sowie Kostenaspekten. Der Verwendung neuer und kostspieliger apparativer Modalitäten und Membrantypen sollte eine klinische Prüfung ihres Nutzens unter Berücksichtigung wichtiger Zielgrößen wie Überleben und Erhalt der Nierenfunktion vorangehen.

Acute Renal Failure: Extracorporal RenaI Replacement Therapy and Peritoneal Dialysis.

Therapy of prolonged acute renal failure regularly requires a renal replacement therapy. This can be achieved by different extracorporal renal replacement therapies (ERRT) or by peritoneal dialysis. ERRT are classified according to the physical principle underlying toxin elimination as hemodialysis (diffusion) and hemofiltration (convection). Another classification refers to intermittent or continuous application modes. Biocompatibility of membranes is judged according to their activation of the complement system. Prospective randomized studies did not consolidate the assumptions about the benefit of particular modalities proposed on theoretical foundations. Mortality, duration and complication rates of acute renal failure are not significantly decreased by use of biocompatible membranes. Continuous modalities are not generally preferable but optimize treatment in hemodynamically unstable patients, in whom they endorse fluid balancing and maintenance of sufficient arterial blood pressure. The use of demanding hemofiltration techniques for cytokine removal should be limited to clinical studies. The effects of ERRT-“intensity” and the best timing for initiation of ERRT have not been evaluated sufficiently. The choice of the ERRT modality is subject to clinical judgement (criterion: hemodynamic situation), practical aspects (criteria: availability of equipment and handling experience), and costs. Prior to their general use new and expensive technical modalities and membrane types should be thoroughly evaluated in studies with regard to outcome-related aspects such as patient survival and preservation of renal function.

Schlüsselwörter:

Akutes Nierenversagen - Extrakorporale Nierenersatzverfahren - Hämodialyse - Hämofiltration - Peritonealdialyse

Key words:

Acute renal failure - Extracorporal renal replacement therapy - Hemodialysis - Hemofiltration - Peritoneal dialysis

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