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DOI: 10.1055/a-0853-3928
Organersatzverfahren: Update Nierenersatztherapie
Update: Renal Replacement TherapyPublication History
Publication Date:
19 March 2020 (online)
![](https://www.thieme-connect.de/media/ains/202003/lookinside/thumbnails/10-1055-a-0853-3928_ai_zarbock-1.jpg)
Zusammenfassung
Die steigende Inzidenz der schweren akuten Nierenschädigung in Verbindung mit weiterhin hohen Mortalitätsraten stellt die intensivmedizinische Versorgung vor eine wachsende Herausforderung. Nierenersatzverfahren sind die wichtigste Therapiemaßnahme und kommen gleichermaßen zunehmend zum Einsatz – ungeachtet dessen werden wesentliche Aspekte ihrer Umsetzung infolge einer eingeschränkten Evidenzlage kontrovers diskutiert.
Abstract
Renal replacement therapy (RRT) remains the cornerstone of treatment for severe acute kidney injury. However, despite its spreading use along with rising incidences of acute kidney injury, evidence of most recommendations is limited so far. Early initiation of RRT seems to reduce mortality but is associated with higher incidence of adverse events. Continuous RRT is advantageous in terms of hemodynamic control and decreased incidence of chronic dialysis dependency but without affecting mortality. Regional citrate anticoagulation should be preferred with regard to longer filter circuit life span. Intensified RRT with a prescribed dose ≥ 35 mL/kg/h has no benefit with regard to mortality but is associated with higher occurrence of complications. Urine output has the best prognostic value for cessation of RRT. Biomarkers of renal impairment and recovery are needed for better guidance of therapy.
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Infolge der steigenden Inzidenz der schweren akuten Nierenschädigung (KDIGO-Stadium 3) werden Nierenersatzverfahren immer häufiger eingesetzt.
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Die Evidenzlage vieler Empfehlungen zum Umgang mit Nierenersatzverfahren ist gering.
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Der frühzeitige Beginn eines Nierenersatzverfahrens senkt möglicherweise die Mortalität – bei steigender Komplikationsrate.
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Bei vergleichbarer Mortalitätsrate senken kontinuierliche Nierenersatzverfahren möglicherweise die Inzidenz chronischer Dialysepflichtigkeit gegenüber intermittierenden Dialyseverfahren.
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Die Anlage von Dialysekathetern in die Vv. subclaviae sollte soweit möglich vermieden werden.
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Regionale Citrat-Antikoagulation verlängert die Filterlaufzeit ohne nachweisbaren Vorteil hinsichtlich der Mortalität.
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Intensivierte Ablaufdosen sollten bei höherer Komplikationsrate und gleicher Mortalität vermieden werden.
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Zur Evaluation der Beendigung der Nierenersatztherapie sollte die Urinausscheidung verwendet werden.
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Literatur
- 1 KDIGO AKI Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2: 1-138 doi:10.1038/kisup.2012.1
- 2 Birnie K, Verheyden V, Pagano D. et al. Predictive models for kidney disease: improving global outcomes (KDIGO) defined acute kidney injury in UK cardiac surgery. Crit Care 2014; 18: 606 doi:10.1186/s13054-014-0606-x
- 3 Thakar CV, Arrigain S, Worley S. et al. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol 2004; 16: 162-168 doi:10.1681/ASN.2004040331
- 4 Biteker M, Dayan A, Tekkeşin Aİ. et al. Incidence, risk factors, and outcomes of perioperative acute kidney injury in noncardiac and nonvascular surgery. Am J Surg 2014; 207: 53-59 doi:10.1016/j.amjsurg.2013.04.006
- 5 Sawhney S, Mitchell M, Marks A. et al. Long-term prognosis after acute kidney injury (AKI): what is the role of baseline kidney function and recovery? A systematic review. BMJ Open 2015; 5: e006497 doi:10.1136/bmjopen-2014-006497
- 6 Uchino S, Kellum JA, Bellomo R. et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294: 813-818 doi:10.1001/jama.294.7.813
- 7 Al-Jaghbeer M, Dealmeida D, Bilderback A. et al. Clinical decision support for in-hospital AKI. J Am Soc Nephrol 2018; 29: 654-660 doi:10.1681/ASN.2017070765
- 8 Hoste EAJ, Bagshaw SM, Bellomo R. et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med 2015; 41: 1411-1423 doi:10.1007/s00134-015-3934-7
- 9 Hsu RK, McCulloch CE, Dudley RA. et al. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol 2013; 24: 37-42 doi:10.1681/ASN.2012080800
- 10 Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int 2012; 81: 442-448 doi:10.1038/ki.2011.379
- 11 Ishani A, Xue JL, Himmelfarb J. et al. Acute kidney injury increases risk of ESRD among elderly. J Am Soc Nephrol 2009; 20: 223-228 doi:10.1681/ASN.2007080837
- 12 Liang KV, Sileanu FE, Clermont G. et al. Modality of RRT and recovery of kidney function after AKI in patients surviving to hospital discharge. Clin J Am Soc Nephrol 2016; 11: 30-38 doi:10.2215/CJN.01290215
- 13 Bouchard J, Soroko SB, Chertow GM. et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009; 76: 422-427 doi:10.1038/ki.2009.159
- 14 Zarbock A, Kellum JA, Schmidt C. et al. Effect of early vs. delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The ELAIN randomized clinical trial. JAMA 2016; 315: 2190-2199 doi:10.1001/jama.2016.5828
- 15 Park JY, An JN, Jhee JH. et al. Early initiation of continuous renal replacement therapy improves survival of elderly patients with acute kidney injury: a multicenter prospective cohort study. Crit Care 2016; 20: 260 doi:10.1186/s13054-016-1437-8
- 16 Gaudry S, Hajage D, Schortgen F. et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med 2016; 375: 122-133 doi:10.1056/NEJMoa1603017
- 17 Barbar SD, Clere-Jehl R, Bourredjem A. et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med 2018; 379: 1431-1442 doi:10.1056/NEJMoa1803213
- 18 Fayad AII, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018; (12) CD010612 DOI: 10.1002/14651858.CD010612.pub2.
- 19 Vinsonneau C, Camus C, Combes A. et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 2006; 368: 379-385 doi:10.1016/S0140-6736(06)69111-3
- 20 Bagshaw SM, Berthiaume LR, Delaney A. et al. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis. Crit Care Med 2008; 36: 610-617 doi:10.1097/01.CCM.0B013E3181611F552
- 21 Truche AS, Darmon M, Bailly S. et al. Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery. Intensive Care Med 2016; 42: 1408-1417 doi:10.1007/s00134-016-4404-6
- 22 Zhang L, Yang J, Eastwood GM. et al. Extended daily dialysis versus continuous renal replacement therapy for acute kidney injury: a meta-analysis. Am J Kidney Dis 2015; 66: 322-330 doi:10.1053/j.ajkd.2015.02.328
- 23 Wald R, Shariff SZ, Adhikari NKJ. et al. The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study. Crit Care Med 2014; 42: 868-877 doi:10.1097/CCM.0000000000000042
- 24 Lund A, Damholt MB, Wiis J. et al. Intracranial pressure during hemodialysis in patients with acute brain injury. Acta Anaesthesiol Scand 2019; 63: 493-499 doi:10.1111/aas.13298
- 25 Cimochowski GE, Worley E, Rutherford WE. et al. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 1990; 54: 154-161 doi:10.1159/000185837
- 26 Schillinger F, Schillinger D, Montagnac R. et al. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6: 722-724 doi:10.1093/ndt/6.10.722
- 27 Parienti JJ, Thirion M, Mégarbane B. et al. Femoral vs. jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: A randomized controlled trial. JAMA 2008; 299: 2413-2422 doi:10.1001/jama.299.20.2413
- 28 Parienti JJ, Mégarbane B, Fischer MO. et al. Catheter dysfunction and dialysis performance according to vascular access among 736 critically ill adults requiring renal replacement therapy: A randomized controlled study. Crit Care Med 2010; 38: 1118-1125 doi:10.1097/CCM.0b013e3181d454b3
- 29 Rabindranath KS, Kumar E, Shail R. et al. Use of real-time ultrasound guidance for the placement of hemodialysis catheters: A systematic review and meta-analysis of randomized controlled trials. Am J Kidney Dis 2011; 58: 964-970 doi:10.1053/j.ajkd.2011.07.025
- 30 Schneider AG, Journois D, Rimmelé T. Complications of regional citrate anticoagulation: accumulation or overload?. Crit Care 2017; 21: 281 doi:10.1186/s13054-017-1880-1
- 31 Khadzhynov D, Dahlinger A, Schelter C. et al. Hyperlactatemia, lactate kinetics and prediction of citrate accumulation in critically ill patients undergoing continuous renal replacement therapy with regional citrate anticoagulation. Crit Care Med 2017; 45: e941-e946 doi:10.1097/CCM.0000000000002501
- 32 Hetzel GR, Schmitz M, Wissing H. et al. Regional citrate versus systemic heparin for anticoagulation in critically ill patients on continuous venovenous haemofiltration: a prospective randomized multicentre trial. Nephrol Dial Transplant 2011; 26: 232-239 doi:10.1093/ndt/gfq575
- 33 Gattas DJ, Rajbhandari D, Bradford C. et al. A randomized controlled trial of regional citrate versus regional heparin anticoagulation for continuous renal replacement therapy in critically ill adults. Crit Care Med 2015; 43: 1622-1629 doi:10.1097/CCM.0000000000001004
- 34 Liu C, Mao Z, Kang H. et al. Regional citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill patients: a meta-analysis with trial sequential analysis of randomized controlled trials. Crit Care 2016; 20: 144 doi:10.1186/s13054-016-1299-0
- 35 Slowinski T, Morgera S, Joannidis M. et al. Safety and efficacy of regional citrate anticoagulation in continuous venovenous hemodialysis in the presence of liver failure: the Liver Citrate Anticoagulation Threshold (L-CAT) observational study. Crit Care 2015; 19: 349 doi:10.1186/s13054-015-1066-7
- 36 Bai M, Zhou M, He L. et al. Citrate versus heparin anticoagulation for continuous renal replacement therapy: an updated meta-analysis of RCTs. Intensive Care Med 2015; 41: 2098-2110 doi:10.1007/s00134-015-4099-0
- 37 VA/NIH Acute Renal Failure Trial Network. Palevsky PM, Zhang JH. et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359: 7-20 doi:10.1056/NEJMoa0802639
- 38 RENAL Replacement Therapy Study Investigators. Bellomo R, Cass A. et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009; 361: 1627-1638 doi:10.1056/NEJMoa0902413
- 39 Fayad AI, Buamscha DG, Ciapponi A. Intensity of continuous renal replacement therapy for acute kidney injury. Cochrane Database Syst Rev 2016; (10) CD010613 DOI: 10.1002/14651858.CD010613.pub2.
- 40 Wang Y, Gallagher M, Li Q. et al. Renal replacement therapy intensity for acute kidney injury and recovery to dialysis independence: a systematic review and individual patient data meta-analysis. Nephrol Dial Transplant 2017; 33: 1017-1024 doi:10.1093/ndt/gfx308
- 41 Uchino S, Bellomo R, Morimatsu H. et al. Discontinuation of continuous renal replacement therapy: A post hoc analysis of a prospective multicenter observational study. Crit Care Med 2009; 37: 2576-2582 doi:10.1097/CCM.0b013e3181a38241
- 42 Wu B, Yan W, Li X. et al. Initiation and cessation timing of renal replacement therapy in patients with type 1 cardiorenal syndrome: An observational study. Cardiorenal Med 2017; 7: 118-127 doi:10.1159/000454932
- 43 Chawla LS, Davison DL, Brasha-Mitchell E. et al. Development and standardization of a furosemide stress test to predict the severity of acute kidney injury. Crit Care 2013; 17: R207 doi:10.1186/cc13015
- 44 Rewa OG, Bagshaw SM, Wang X. et al. The furosemide stress test for prediction of worsening acute kidney injury in critically ill patients: A multicenter, prospective, observational study. J Crit Care 2019; 52: 109-114 doi:10.1016/j.jcrc.2019.04.011
- 45 Goldstein SL, Chawla LS. Renal angina. Clin J Am Soc Nephrol 2010; 5: 943-949 doi:10.2215/CJN.07201009