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Akutes Nierenversagen und Sepsis

Nur eine Organdysfunktion bei septischem Multiorganversagen?

Acute renal failure and sepsis

Just an organ dysfunction due to septic multiorgan failure?

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Zusammenfassung

Das akute Nierenversagen (ANV) ist als eine plötzliche, prinzipiell reversible Verschlechterung der glomerulären und tubulären Funktion definiert. Pathophysiologisch kann man zwischen einem ischämischen und einem toxisch verursachten ANV unterscheiden. Die Sepsis ist die häufigste Ursache eines ANV auf der Intensivstation, und das ANV ist ein unabhängiger Risikofaktor für die Letalität septischer Patienten. Interventionen zur Nephroprotektion – und damit der Prophylaxe eines ANV in der Sepsis – beruhen im Wesentlichen auf der Beeinflussung der renalen Hämodynamik. Hierzu gehören eine adäquate Volumensubstitution und der Einsatz von Vasokonstriktoren. Dabei sollte bei Einsatz von Kolloiden die maximale Tagesdosis nicht überschritten und es sollten hyperonkotische kolloidale Lösungen vermieden werden. Niedrig dosiertes Dopamin zur Prophylaxe des ANV ist obsolet. Schleifendiuretika steigern die Urinproduktion und führen über eine Optimierung der Bilanzierungsmöglichkeit zu einem Nutzen extrarenaler Organe, verbessern jedoch weder die Nierenfunktion noch das Outcome. Deshalb sind Diuretika zur kausalen Behandlung eines drohenden oder manifesten ANV bei septischen Patienten nicht indiziert. Für die Nierenersatztherapie stehen intermittierende und kontinuierliche Therapieverfahren zur Verfügung. Kontinuierliche oder intermittierende sowie konvektive oder diffusive Verfahren sind prinzipiell gleichwertig, wenn eine Mindestultrafiltrationsrate ≥20 ml/h•kgKG oder ein Therapieintervall ≥ 3-mal/Woche eingehalten wird.

Abstract

Acute renal failure (ARF) is clinically defined as an abrupt, but in principle reversible deterioration of glomerular and tubular function. Regarding pathophysiology, ARF is caused by ischemic renal conditions and toxic mediators. Sepsis is the most common cause of ARF in the intensive care unit and ARF is an independent risk factor for lethality of septic patients. Interventions to protect the kidneys against ARF include preliminary optimization of renal perfusion by volume load with cristalloid solutions and the administration of vasopressors. Daily maximum permissible dosages for colloids should not be exceeded and hyperoncotic colloid solutions should be generally avoided. Dopamine in “renal dosage” is nowadays obsolete. Loop diuretics produce diuresis and can be beneficial to extrarenal organs by improving fluid homeostasis, however diuretics do not improve kidney function and outcome. Therefore, diuretics are not indicated for patients with imminent or existing ARF. Septic patients with ARF can be treated by intermittent and continuous forms of renal replacement therapy, whereas continuous convective and intermittent diffusive methods are equivalent when utilizing an ultrafiltration rate ≥20 ml/h•kg body weight or a therapeutic interval ≥3 times/week.

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  1. Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle, Deutschland

    C. Schmidt, T. Steinke, S. Moritz & M. Bucher

  2. Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland

    B.M. Graf

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  1. C. Schmidt
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Correspondence to C. Schmidt.

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Schmidt, C., Steinke, T., Moritz, S. et al. Akutes Nierenversagen und Sepsis. Anaesthesist 59, 682–699 (2010). https://doi.org/10.1007/s00101-010-1767-x

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