Diagnose und Therapie: Akutes Nierenversagen. Abteilung Nephrologie und und Hypertensiologie

Transcription

1 Diagnose und Therapie: Akutes Nierenversagen Jan Jan T. T. Kielstein Abteilung Nephrologie und und Hypertensiologie MHH MHH

2 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Beginn der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

3 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Beginn der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

4 Acute renal failure Acute Kidney Injury

5 Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury MEHTA et al Crit Care Med, 11:2, R21, 2007 General Definition: Acute kidney Injury (AKI) is is defined as as functional or or structural abnormalities or or markers of of kidney damage including abnormalities in in blood, urine or or tissue tests or or imaging studies present for less than three months Diagnostic criteria for AKI : an an abrupt (within hours) reduction in in kidney function : absolute increase in in serum creatinine of of either > 0.3 mg/dl (>25 micromole/l) or or a percentage increase of of 50% or or a reduction in in urine output (documented oliguria of of < 0.5 ml/kg/hr for > 6 hours)

6 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Beginn der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

7 Acute Renal Failure in critically ill patients (n=29,260) A multinational, multicenter study UCHINO et al. JAMA 294: , 2005 Overall mortality: 60.3 %

8 Effect of acute renal failure requiring renal replacement therapy on outcome in (17,126) critically ill patients METNITZ et al Crit Care Med 30: , 2002

9 Hospitalization Discharge Diagnoses for Kidney Disease -United States, CDC MMWR 57(12); ,

10 Acute Renal Failure in critically ill patients (n=29,260) A multinational, multicenter study UCHINO et al. JAMA 294: , 2005

11 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Begin der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

12 Lack of renoprotective effects of dopamine and furosemide during cardiac surgery LASSNIGG et al. J Am Soc Nephrol 11(1):97-104, 2000

13 Diuretics, mortality and non-recovery of renal function in ARF MEHTA et al. JAMA 288: , 2002 Lasix ohne Volumen ist wie Denken ohne Hirn JTK

14 Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death FRIEDRICH et al. Ann Intern Med 142:510-24, 2005 Renal dose Dopa hilft und die Erde ist eine Scheibe JTK

15 Prärenales Nierenversagen.sagte das Schneiderlein,»das ist bei unsereinem Spielwerk«, griff in die Tasche, holte den weichen Käs und drückte ihn, daß der Saft herauslief.»gelt«, sprach er,»das war ein wenig besser?«der Riese wußte nicht, was er sagen sollte, und konnte es von dem Männlein nicht glauben.

16 A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity TRIVEDI et al. Nephron Clin Pract 93(1):C29-34, 2003 Patients received either: saline at at 1 ml/kg per per hour for for hours pre pre and and post procedure or or nothing incidence of ARF 3.7% 34.6%

17 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Beginn der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

18 Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. SEABRA et al. Am J Kidney Dis. 52(2):272-84, 2008 Urea : mmol/l 27-71

19 Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. SEABRA et al. Am J Kidney Dis. 52(2):272-84, randomized prospective studies

20 Timing of renal replacement therapy and clinical outcomes in critically ill patients (n=1,238) with severe acute kidney injury. BAGSHAW et al. J Crit Care. 24(1):129-40, 2009

21 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Beginn der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

22 September 11 th year-old Maria Schafstaat initial dialysis treatment lasted 690 min (i.e hours) blood flow was 116 ml/min urea reduction rate 69% (i.e. pre-and posttreatment urea serum concentrations were 396 and 121 mg/dl) calculated urea clearance was 87 ml/min and Kt/V patient went on to to become nonoliguric, followed by gradual recovery of of urea clearance. patient survived her acute illness, left the hospital

23 EDD: the way Kolff treated ARF

24 Arteriovenous Haemofiltration: A New and Simple Method for Treatmentof Over-hydrated Patients Resistant to Diuretics KRAMER et al Klin. Wschr. 55, , 1977

25 Practice patterns in the management of acute renal failure in the critically ill patient: an international survey RICCI et al. Nephrol Dial Transpl, 21: , 2006

26 ARF in the ICU: a systematic review of the impact of dialytic modality on mortality and renal recovery TONELLI et al. AJKD 40: , 2002

27 Dialysing the patient with acute renal failure in the ICU: the emperors clothes? LAMEIRE et al Nephrol Dial Transplant 14: , 1999 We firmly believe that to ensure optimal dialysis treatment for the ARF patient in the ICU, the skills and the experience of the physicians and nurses who perform dialysis are more important than the applied dialysis modality.

28 Diagnose und Therapie: Akutes Nierenversagen 1) Definition ANV/ Acute kidney injury 2) Acute renal failure-not a cute renal failure 3) Prävention des ANV/ Was funktioniert nicht? 4) Begin der Nierenersatztherapie 5) Arten der Nierenersatztherapie 6) Dosis der Nierenersatztherapie

29 Delivery of Renal Replacement Therapy in Acute Kidney Injury: What Are the Key Issues? DAVENPORT et al. CJASN, 3(3):869-75, 2008

30 Practice patterns in the management of acute renal failure in the critically ill patient: an international survey RICCI et al. Nephrol Dial Transpl, 21: , 2006

31 Effects of different doses in CVVH on outcomes of acute renal failure: a prospective randomised trial RONCO et al. Lancet 365: 26-30, 2000 Group 1: 20 ml/h/kg Group 2: 35 ml/h/kg Group 3: 45 ml/h/kg

32 Intensity and renal support in critically ill patients with acute kidney injury The VA/NIH Acute Renal Trial network NEJM online publication

33 Autor RRT N Überleben LD Überleben HD Ronco 2000 CVVH % 20 ml/kg/h 57 % 35 ml/kg/h Schiffl 2002 IHD % wkt/v 3,0 72 % wkt/v 5,8 Bouman 2002 CVVH % 19 ml/kg/h 74% 48 ml/kg/h Saudan 2006 CVVH/DF % 23 ml/kg/h 59 % 48 ml/kg/h Tolwani 2008 CVVHDF % 20 ml/kg/h 49 % 35 ml/kg/h Palevsky 2008 IHD,SLED CVVH % 20 ml/kg/h 46% 35 ml/kg/h Faulhaber 2009 SLED % Urea % Urea < 15

34 Autor RRT N Überleben LD Überleben HD Ronco 2000 CVVH % 20 ml/kg/h 57 % 35 ml/kg/h Schiffl 2002 IHD % wkt/v 3,0 72 % wkt/v 5,8 Bouman 2002 CVVH % 19 ml/kg/h 74% 48 ml/kg/h Saudan 2006 CVVH/DF % 23 ml/kg/h 59 % 48 ml/kg/h Tolwani 2008 CVVHDF % 20 ml/kg/h 49 % 35 ml/kg/h Palevsky 2008 IHD,SLED CVVH % 20 ml/kg/h 46% 35 ml/kg/h Faulhaber 2009 SLED % Urea % Urea < 15

35 Vancomycin bei Dialysepatienten alle 1-2 Wochen 1g

36 Dosing regimen from the vinyl age for RRT of the i-pod era?

37 Dose of renal replacement therapy in acute kidney injury KIELSTEIN Dtsch Med Wochenschr 134: 1 3, 2009

38

39 Besser langsam gepinkelt als schnell dialysiert!