Nierenfunktionstörungen

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1 Die Niere wackelt: Warum ist das so wichtig? Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery Lassnigg Andrea et al. JASN 2004; 15: AKE-Pflege-Seminar Wien, 20. November 2009 Wilfred Druml Abteilung für Nephrologie und Dialyse Medizinische Universitätsklinik III, Wien 30-day mortality and change in serum creatinine within 48 h after cardiac surgery (calculated for intervals of Crea 0.1 mg/dl) Acute kidney injury, mortality, length of stay,, and costs in hospitalized patients Chertow GM et al. J Am Soc Nephrol. 2005;16: Nierenfunktionstörungen Prognostische Bedeutung Mortality associated with change in serum creatinine. Green bars = unadjusted, blue bars = age/ gender adjusted, gray bars = multivariable adjusted (for age, gender, diagnosis-related group (DRG) weight, chronic kidney disease (CKD), ICD-9-CM codes for respiratory, gastrointestinal, malignant, infectious diseases Schon kleinste Änderungen des Serum- Kreatinin haben einen ausgeprägten prädiktiven Wert für Krankheitsverlauf und Prognose Das Schicksal eines (Intensiv-) Patienten entscheidet sich ganz früh im Krankheitsverlauf ( < 6 bis 12 h) RIFLE Criteria for Acute Renal Dysfunction GFR Criteria* Urine Output Criteria Definition des AKI : Ein Vorschlag nach Joannidis M und Druml W, IntensivNews 1/2009 Risk Increased creatinine x1.5 or GFR decrease > 25% UO <.5ml/kg/h x 6 hr High Sensitivity Injury Increased creatinine x2 or GFR decrease > 50% UO <.5ml/kg/h x 12 hr Failure Increase creatinine x3 or GFR decrease > 75% (or Crea > 4) UO <.3ml/kg/h x 24 hr or Anuria x 12 hrs High Specificity Loss ESRD Persistent ARF** = complete loss of renal function > 4 weeks End Stage Renal Disease nach Bellomo R; Crit Care 2004; 8: R204 * * Änderung des Kr innerhalb 48 h ** Notwendigkeit der Nierenersatztherapie grundsätzlich Stadium 3 (siehe auch Mehta R; Crit Care 2007; 11:R31) 1

2 NIERENFUNKTION Patient I : 32 a, m, Body-Builder Builder Aufnahme wegen Glutealabszeß KG 98 kg, Grösse 184 cm Serum Kr 2.0 mg/dl Was ist seine Kreatinin-Clearance? ml/min ml/min ml/min ml/min Serum - Kreatinin NIERENFUNKTION Serum - Kreatinin Patient II : 84 a, w KG 43 kg, Grösse 158 cm Serum Kr 1.8 mg/dl Was ist ihre Kreatinin-Clearance? ml/min ml/min ml/min ml/min NIERE & ALTER Serum-Kreatinin und Nierenfunktion Alter Serum - Kreatinin Kreatinin - Clearance (Jahre) (mg/dl) (ml/min per 1.73 m 2 ) Prognose des akuten Nierenversagens Eine alte Nephrologen-Weisheit Kein Patient verstirbt am akuten Nierenversagen, sondern nur im ANV, da ja die Nierenfunktion leicht beliebig lange ersetzt werden kann... Pre-existing existing renal disease promotes sepsis-induced induced acute kidney injury and worsens outcome Doi K et al Kidney Int 2008; 74: (a) Survival analysis of folic acid induced AKI with sepsis 2 weeks later (FA-CLP) and Veh-CLP. (b, c) Renal function of Veh-CLP and FA-CLP mice. BUN and serum Cr 0 and 18 h after CLP Effect of ARF Requiring Renal Replacement Therapy on Outcome in Critically Ill Patients Metnitz PGH et al. Crit Care Med 2002; 30: Objective : To analyze the severity of illness and mortality in critically ill patients with ARF requiring RRT Design : Prospective multicenter cohort study Patients : 17,126 pts. admitted to 30 Austrian ICUs Main results: : 4.9 % = 839 patients with ARF mortality 62.8 % vs % p < Case control comparison: : age, gender, severity : mortality 62.8 % vs %; p < multivariate analysis: pos.effect: enteral nutrition neg. effect: ventilation, hemodyn. support,, CRP, acidosis but not : age, late-onset RRT 2

3 PROGNOSIS in Acute Renal Failure Hospital Mortality, % NON-RRT RRT >31 RRT = renal replacement therapy Severity of illness (SAPS II - Score) Data from ASCI- Vienna Systemische Folgen eines ANV kardiovaskulär: Hyperzirkulation, Kardiomyopathie, Perikariditis pulmonal : Lungenödem, Alveolitis, Pneumonie, Blutung gastrointestinal : Erosionen, Ulzerationen, Blutungen, Pankreatitis, Colitis neuromusculär : Neuropathie, Myopathie, Enzephalopathie immunologisch : Störung der humoralen und zell. Immunität hämatologisch : Anämie, Thrombocytopenie, hämorrhagische Diathese metabolisch: Proteinkatabolism, Insulin-Resistenz, Hypertriglyceridämie etc., etc. Renal ischemia/ reperfusion leads to macrophage-mediated mediated increase in pulmonary vascular permeability Kramer AA et al Pulmonary histology 24 h after renal ischemia/ reperfusion injury (IRI). Sham rats : paucity of interstitial red blood cells or edema at 24 h viewed at low (A) or high (B) power. Renal IRI : vascular congestion with red cells, intra-alveolar hemorrhage (C). Renal IRI : interstitial edema, no hyaline membranes (D). Treatment with CNI-1493 : decrease in hemorrhage (E); accumulation of interstitial red blood cells and increased edema still prominent (F). Kidney Int 1999; 25: 2563 Acute renal failure: determinants and characteristics of the injury-induced hyperinflammatory response Zager RA et al Am J Physiol 2006; 291: F Plasma TNF-α and MCP-1 in glycerol-induced ARF (Gly) and controls (C) ± LPS. Left: TNF-α barely detectable in C and Gly (zero values). LPS induced TNF-α increases in C and Gly, 300% higher in Gly-ARF. Right: MCP-1 levels were elevated in the non-lps-arf vs. C, (as "zero. ). LPS increased MCP-1 levels in 2 groups Uremic lung: new insights into a forgotten condition Scheel PJ et al Kidney int 2008; 74: AKI-induced distant organ effects. AKI leads to changes in distant organs, including brain, lungs, heart, liver, gastrointestinal tract, and bone marrow. (changes in organ function, microvascular inflammation and coagulation, cell apoptosis, transporter activity, oxidative stress, and transcriptional responses). Das Enigma ANV Entwicklung der Mortalität währen 30 Jahre Myokard-Infarkt Mortalität 50 % 6 % Akutes Nierenversagen Mortalität 50 % 60 % 3

4 Effect of acute kidney injury on weaning from mechanical ventilation in critically ill patients Vieira JM et al. Crit Care Med 2007; 35 : Kaplan-Meier curves for the effect of oliguria (left) and an increase of 85% in baseline creatinine (SCr) during ICU stay (right) on cumulative weaning from mechanical ventilation Effect of acute kidney injury on weaning from mechanical ventilation in critically ill patients Vieira JM et al. Crit Care Med 2007; 35 : ERGEBNISSE : AKI-Patienten hatten initial einen gleichen APACHE II - Score, aber erhöhtes Auftreten von schw. Sepsis/ septischer Schock, höheren Antibiotika-Bedarf Bedarf, benötigten länger vasoaktive Medikamente; mussten länger beatmet werden; hatten ein verzögertes Weaning, einen längeren Intensivaufenthalt und höhere Mortalität Renal dysfunction and serious infections after open-heart surgery Thaker CV et al. Kidney int 2003; 64: 239 Central venous catheter-related related bloodstream infections: improving post-insertion catheter care Shapey IM et al. J Hosp Infect 2009; 71: The relationship between preoperative creatinine clearance (ml/min) and frequency of infections Breach rate according to ward and aspect of care. HDU, high-dependency unit; ; ICU, intensive care unit. Risk of Bloodstream Infection in Patients With Chronic Kidney Disease Not Treated With Dialysis James MT et al. Arch int Med 2008; 168: 2333 Todesursachen bei ANV Woodrow G & Truney JH Nephrol Dial Transplant 1992; 7: Kaplan-Meier curves for first bloodstream infection according to estimated glomerular filtration rate (egfr; ml/min/1.73 m2). Cause of death in acute renal failure (percentage) by decade of presentation 4

5 Diuretics, Mortality,, and Nonrecovery of Renal Function in Acute Renal Failure Mehta Ravindra L et al JAMA 2002; 288: EFFECTS OF SALINE, MANNITOL, AND FUROSEMIDE ON ACUTE DECREASES IN RENAL FUNCTION INDUCED BY RADIOCONTRAST AGENTS Solomon R. et al N Engl J Med 1994; 321: Time to Death or Dialysis From Day of Consultation in Intensive Care Unit Serum Creatinine Concentrations Immediately before the Administration of Radiocontrast Agent (after 12 Hours of Hydration) and 48 Hours Later in Patients with Chronic Renal Insufficiency Lack of Renoprotective Effecte of Dopamin and Furosemide in Cardiac Surgery Lassnig Andrea et al J Am Soc Nephrol 2000; 11: (A) Maximal increase of serum creatinine within 48 h (Crea max ) in the three study groups receiving either dopamine, furosemide, or placebo. (B) Crea max in patients receiving additional bolus injections of furosemide High-dose furosemide for established ARF: A prospective, randomized, double-blind, placebo-controlled trial Furosemide Placebo Significance (P) Patients alive at the end of the study (n = 221) SAPS * SAPS > Total Deaths (n = 109) SAPS SAPS > Total No. of RRT sessions SAPS ± ± SAPS > ± ± 5.6 Total 6.5 ± ± 5.3 Time on RRT (d) 11.4 ± ± Time to achieve a serum creatinine level <2.26 mg/dl without RRT (d) 19.7 ± ± Time to achieve a 2-L/d diuresis (d) 5.7 ± ± from Cantarovich F et al. Am J Kidney Dis 2004; 44: Diuretika Mögliche Probleme von Diuretika Die Niere ist wahnsinnig wichtig! Wir müssen alles tun, um ihre Funktionen zu erhalten! Hypovolämie Elektrolytstörungen(inkl.Hyperparathyreoidismus) Natrium - Rebound Neurohumorale Aktivierung (RAAS) Einschränkung der Nierenfunktion Direkte myokardiale Nebenwirkungen (Progression des CHF) Verlust von wasserlöslichen Vitaminen (Thiamin!) (kardiale Kontraktilität ) Danke für Ihre Aufmerksamkeit! 5