S1-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Zusammenarbeit mit der AKE, der GESKES und der DGfN^[1]

Zusammenfassung

Fragestellung: Patienten mit Niereninsuffizienz bilden eine sehr heterogene Gruppe von Personen mit unterschiedlichen metabolischen Störungen und Bedarf an Nährstoffen. Zu diesen gehören Patienten mit akutem Nierenversagen (ANV), die rasch zunehmende Zahl von Patienten mit akut-auf-chronischem Nierenversagen (A-C-NV), Patienten mit chronischer Niereninsuffizienz (CNI) und Patienten mit terminaler Niereninsuffizienz unter Nierenersatztherapie (Hämodialyse, Peritonealdialyse), jeweils ohne bzw. mit begleitenden Akuterkrankungen. In der vorliegenden Leitlinie sollen die ernährungstherapeutischen Interventionen, welche in der Betreuung aller dieser Patientengruppen eine entscheidende Rolle für Krankheitsverlauf und Prognose spielen, evidenzbasiert dargestellt werden.

Methodik: Die Leitlinie basiert auf den früheren Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin (DGEM, 2003, 2007), der European Society for Parenteral and Enteral Nutrition (ESPEN, 2006, 2009) und der International Society for Renal Nutrition and Metabolism (ISRNM 2008, 2013). Es wurde eine systematische Analyse der Literatur 2006 – 2014 zur oralen Supplementierung, zur enteralen und parenteralen Ernährung und intradialytischen Ernährung bei diesen Patientengruppen vorgenommen. Die Empfehlungen wurden innerhalb der Arbeitsgruppe sowie dem DGEM Steering Committee verabschiedet.

Ergebnisse: Zur klinischen Ernährung bei Patienten mit Nierenversagen liegen nur wenige randomisiert-kontrollierte Studien vor, sodass die meisten Empfehlungen Expertenmeinungen darstellen. Die Leitlinie umfasst 15 Aussagen und 27 Empfehlungen, wobei in einem Einleitungskapitel die gemeinsamen Aspekte in 15 Aussagen bzw. Empfehlungen abgehandelt werden. Zu der Ernährung von akut-kranken Patienten ohne Nierenersatztherapie gibt es in dieser Leitlinie 5, zu stabilen CNI-Patient ohne Nierenersatztherapie 5, zu akut-krankem Patient unter Nierenersatztherapie 9 und zu chronisch-malnutrierten Hämodialysepatienten 8 Aussagen bzw. Empfehlungen.

Schlussfolgerung: Ernährungsbehandlung und metabolische Führung spielen eine zentrale Rolle in der Betreuung von Patienten mit Nierenfunktionsstörungen. Dabei müssen die metabolischen Folgen der Nierendysfunktion per se, der Komorbiditäten und begleitenden Akuterkrankungen sowie der ausgeprägte Einfluss der Nierenersatztherapie auf Metabolismus und Nährstoffbilanz berücksichtigt werden. Nährstoffbedarf und Ernährungstherapie können sich grundsätzlich zwischen diesen unterschiedlichen Patientengruppen unterscheiden und sich auch individuell im Krankheitsverlauf ganz wesentlich ändern. Damit erfordern gerade Patienten mit Nierenfunktionsstörungen eine individualisierte Planung, Durchführung und Überwachung der Ernährungstherapie.

Abstract

Rationale: Renal failure patients comprise an extremely heterogeneous group of subjects with different metabolic patterns and nutritional requirements. These patients comprise patients with acute kidney injury (AKI), the rapidly increasing number of cases with acute-on-chronic renal failure (A-CRF), chronic kidney disease (CKD) and patients on regular renal replacement therapy (RRT) (haemodialysis, peritoneal dialysis), all with or without associated acute disease processes. In the present guideline, nutritional interventions that have a major impact on morbidity and mortality of these patient groups, will be present in an evidence-based manner.

Methods: These recommendations are based on earlier versions issued by the German Society for Nutritional medicine (DGEM, 2003, 2007), the European Society for Parenteral and Enteral Nutrition (ESPEN, 2006, 2009) and the International Society for Renal Nutrition and Metabolism (ISRNM 2008, 2013). A systematic review of the literature was performed for the years 2006 – 2014 using the search strategies for oral supplementation, for enteral and parenteral nutrition and intradialytic nutrition for the mentioned patient groups. The statements were finally approved by the working-group and the DGEM steering committee.

Results: There are only a few randomized controlled trials available on nutrition support for renal failure patients and thus, most recommendations are based on limited evidence or they represent clinical consensus points. The guideline includes 15 statements and 27 recommendations. In an introductory chapter, common aspects are covered by 15 statements/recommendations. Nutrition in acutely ill renal patients without requirement of RRT is addressed in 5 statements, nutrition in stable CKD patients without RRT in 5, nutrition in acutely ill patients on RRT in 9, and nutrition in malnourished chronic dialysis patients in 8 statements/recommendations.

Conclusions: Nutrition support and metabolic management play a central role in the care of patients with renal dysfunction. Both the metabolic consequences of renal dysfunction per se, and of comorbidities and associated acute disease processes and complications, as well as the profound impact of RRT on metabolism and nutrient balances have to be taken into consideration when designing a nutritional program. It should be noted that nutrition needs may differ widely between these heterogeneous groups of patients but also within the same patient in the course of disease. Thus, patients with renal failure require particularly an individualized approach when designing, delivering and monitoring nutritional support.

Schlüsselwörter

Nierenversagen - Niereninsuffizienz - Hämodialyse - Peritonealdialyse - orale Trinknahrung - enterale Ernährung - parenterale Ernährung - intradialytische Ernährung

Keywords

acute kidney injury - chronic kidney disease - end stage renal disease - hemodialysis - peritoneal dialysis - oral nutritional supplements - enteral nutrition - parenteral nutrition - intradialytic nutrition

¹ DGfN (Deutsche Gesellschaft für Nephrologie)

^* DGEM Steering Committee: Bischoff SC, Lochs H, Weimann A sowie das DGEM-Präsidium

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