Therapie des akuten Nierenversagens - Konzepte und Kontroversen

Zusammenfassung.

Das akute Nierenversagen ist die gemeinsame Endstrecke vielfältiger Schädigungsereignisse. Die Prophylaxe und differenzierte Therapie dieses Krankheitsbildes ist in der Anästhesie und Intensivmedizin von großer Bedeutung. Eine pharmakologische Beeinflussung des akuten Nierenversagens ist nur in engen Grenzen möglich. Diuretika steigern zwar den Harnfluss, verbessern aber weder den Verlauf noch die Prognose des akuten Nierenversagens. Dopamin und natriuretische Peptide sind in der Prophylaxe und Behandlung nicht indiziert. Calcium-Antagonisten spielen lediglich bei der Nierentransplantation eine Rolle. Osmodiuretika verhindern die intratubuläre Präzipitation von Hämoglobin und Myoglobin; sie haben auch bei der Nierentransplantation prophylaktischen Wert. Experimentelle Ansätze zur Förderung der Regeneration der Tubuluszelle durch verschiedene Wachstumsfaktoren sind in vitro und im Tierversuch zwar vielversprechend, doch konnte ihr Nutzen bei der klinischen Applikation nicht belegt werden. Die Physiologie von Stickstoffmonoxid ist in der Niere noch unzureichend untersucht. Fortschritte zeichnen sich beim Verständnis der Lipidperoxidationsprozesse und ihrer pharmakologischen Beeinflussung ab. Entscheidend für die Klinik bleiben die rechtzeitige Erkennung des Risikopatienten und die konsequente Vermeidung nierenschädigender Situationen und Noxen.

Rational Pharmacotherapy and Experimental Strategies in the Treatment of Acute Renal Failure.

Acute renal failure is the common result of various damaging mechanisms. Prophylaxis and differentiated therapy of acute renal failure are of outmost importance in anaesthesiology and intensive care medicine. The efficiency of pharmacotherapy is narrowly limited. Diuretics increase the urine output, but they do neither ameliorate the clinical course of the patient nor the prognosis of established acute renal failure. Dopamine and natriuretic peptides have no use in prevention and treatment of acute renal failure. Calcium-channel-blockers are valuable in cadaveric kidney transplantation. Osmodiuretics prevent intratubular precipitation of hemoglobin and myoglobin crystals; they also have some value in cadaveric kidney transplantation. Experimental studies investigated the possibility to enhance the regeneration of the tubular epithelial cell. Whereas in vitro studies and studies in animal models using various growth factors yielded promising results, these could not be reproduced in patients with acute renal failure. The physiology of NO in the kidney is incompletely understood. Actual progress is made in the understanding of lipid peroxidation and potential pharmacological implications. The mainstay for the assurance of high-quality patient care remain a vigilant identification of the patient at risk and an arduous search to avoid nephrotoxic substances and situations implicating potential renal damage.

Schlüsselwörter:

Akutes Nierenversagen - Pharmakotherapie - Wachstumsfaktoren - Lipidperoxidation

Key words:

Acute renal failure - Pharmacotherapy - Growth factors - Lipid peroxidation

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