Dialysebeginn auf Intensivstation

Zusammenfassung

Die Frage, wann ein Nierenersatzverfahren als eines der zentralen Organersatzverfahren in der Intensivmedizin zu starten sei, kann heute mit den Studien der letzten Jahre deutlich besser beantwortet werden. Hier ist nicht die Höhe des Harnstoff- oder des Kreatininwerts maßgeblich, sondern die klinische Situation des Patienten. Kann bei Abwesenheit von akuten Indikationen (Hyperkaliämie, Azidose, Flüssigkeitsüberladung und Urämie) noch zugewartet werden, so erscheint es sinnvoll, bei der klinischen Erwartung, dass sich die Niere nicht hinreichend erholt, einen Nierenersatz zeitnah zu starten. Auch wenn man damit einen zeitlichen Handlungsspielraum gewinnt, so sollte mit dem Beginn eines anhaltenden schweren Nierenversagen nicht zu lange gewartet werden, bis sich kritische Komplikationen entwickelt haben.

Publication History

Article published online:
04 September 2025

• Literatur

• 1 Singer M, Deutschman CS, Seymour CW. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: 801-810
• 2 Jaber S, Paugam C, Futier E. et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet 2018; 392: 31-40
• 3 Decker BS, Goldfarb DS, Dargan PI. et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol 2015; 10: 875-887
• 4 Karvellas CJ, Farhat MR, Sajjad I. et al. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: A systematic review and meta-analysis. Critical Care 2011; 15: R72
• 5 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
• 6 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
• 7 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
• 8 Bagshaw SM, Wald R, Adhikari NKJ. et al. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med 2020; 383: 240-251
• 9 Gaudry S, Hajage D, Martin-Lefevre L. et al. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet 2021; 397: 1293-1300
• 10 Malbrain ML, Marik PE, Witters I. et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 2014; 46: 361-380
• 11 Goldstein SL, Currier H, Graf C. et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107: 1309-1312
• 12 Vaara ST, Parviainen I, Pettila V. et al. Association of oliguria with the development of acute kidney injury in the critically ill. Kidney Int 2015;
• 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
• 14 Volbeda M, Oord M, Koeze J. et al. Criteria for Continuous Kidney Replacement Therapy Cessation in ICU Patients. Blood Purif 2023; 52: 32-40
• 15 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
• 16 Naorungroj T, Neto AS, Wang A. et al. Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials. Crit Care 2022; 26: 269
• 17 Wald R, Kirkham B, daCosta BR. et al. Fluid balance and renal replacement therapy initiation strategy: a secondary analysis of the STARRT-AKI trial. Crit Care 2022; 26: 360
• 18 Beaubien-Souligny W, Yang Y, Burns KEA. et al. Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy. Ann Intensive Care 2021; 11: 96
• 19 Rabindranath K, Adams J, Macleod AM. et al. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev 2007; (3) CD003773
• 20 Russo DS, Eugenio CS, Balestrin IG. et al. Comparison of hemodynamic instability among continuous, intermittent and hybrid renal replacement therapy in acute kidney injury: A systematic review of randomized clinical trials. J Crit Care 2022; 69: 153998
• 21 Ronco C, Bellomo R, Homel P. et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356: 26-30
• 22 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
• 23 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
• 24 Roberts DM, Roberts JA, Roberts MS. et al. Variability of antibiotic concentrations in critically ill patients receiving continuous renal replacement therapy: a multicentre pharmacokinetic study. Crit Care Med 2012; 40: 1523-1528
• 25 Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 2002; 346: 305-310
• 26 Faulhaber-Walter R, Hafer C, Jahr N. et al. The Hannover Dialysis Outcome study: comparison of standard versus intensified extended dialysis for treatment of patients with acute kidney injury in the intensive care unit. Nephrol Dial Transplant 2009; 24: 2179-2186
• 27 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 2018; 33: 1017-1024