Volumentherapie und Nierenschädigung – was gibt es Neues?

Was ist neu?

Welche Menge an Volumenersatzstoff geben? Im Schock erfolgt die Flüssigkeitstherapie mit Kristalloiden nach zielgerichteten Kriterien und unter Kontrolle des Laktats. Zur Wiederherstellung des Reäquilibriums ist oft eine Negativbilanz durch Flüssigkeitsrestriktion, Schleifendiuretika und maschinelle Ultrafiltration erforderlich. Bei einer maschinellen Ultrafiltration sollten 1,75 ml/kg/h nicht überschritten werden.

Welche Volumenersatzstoffe geben? Balancierte Kristalloide sind Mittel der Wahl zur Flüssigkeitstherapie. Neue Volumenersatzstoffe mit einer höheren Anionenlücke haben einen alkalisierenden Effekt und können möglicherweise die Flüssigkeitstherapie optimieren.

Welche Volumenersatzstoffe führen zu AKI? Kochsalz führt aufgrund einer hyperchlorämischen Azidose in moderaten Mengen zu einer funktionellen Einschränkung der renalen Filtration. In höheren Mengen ist NaCl mit einem schlechten Outcome vergesellschaftet. HES und vermutlich auch Gelatine haben zytotoxische Effekte und können zu einer akuten Nierenschädigung führen.

Abstract

Optimization of intravascular volume is crucial for patients who are at risk or undergo Acute Kidney Injury. In sepsis or after acute fluid loss extensive fluid expansion is mostly needed. However, in cardiorenal syndroms fluid overload can even lead to AKI itself and reduction of intravascular volume is needed. Thus, an individualized fluid guidance in terms of a „fluid management stewartship“ for the right patient, the right drug, the right route and the right dose [1] has to be applied.

Schlüsselwörter

Flüssigkeitstherapie - akute Nierenschädigung - Kochsalz - Albumin

Key words

fluid therapy - acute kidney injury - critical care - saline - albumine

Publication History

Article published online:
03 August 2021

• Literatur

• 1 Hawkins WA, Smith SE, Newsome AS. et al. Fluid Stewardship During Critical Illness: A Call to Action. J Pharm Pract 2020; 33: 863-873
• 2 Willam C, Herbst L, Kribben A. Flüssigkeitsmanagement in der Intensivmedizin. Nephrologe 2019; 14: 413-421
• 3 Marik PE, Byrne L, van Haren F. Fluid resuscitation in sepsis: the great 30 mL per kg hoax. J Thorac Dis 2020; 12: S37-S47
• 4 Rivers E, Nguyen B, Havstad S. et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England journal of medicine 2001; 345: 1368-1377
• 5 Vincent JL. Intravascular Volume Assessment in the Critically Ill Patient. Clinical journal of the American Society of Nephrology: CJASN 2020; 15: 557-559
• 6 Messmer AS, Zingg C, Muller M. et al. Fluid Overload and Mortality in Adult Critical Care Patients-A Systematic Review and Meta-Analysis of Observational Studies. Crit Care Med 2020; 48: 1862-1870
• 7 Murugan R, Kerti SJ, Chang CH. et al. Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration: A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial. JAMA Netw Open 2019; 2: e195418
• 8 Naorungroj T, Neto AS, Zwakman-Hessels L. et al. Early net ultrafiltration rate and mortality in critically ill patients receiving continuous renal replacement therapy. Nephrology, dialysis, transplantation: official publication of the European Dialysis and Transplant Association – European Renal Association 2020;
• 9 Pfortmueller CA, Faeh L, Muller M. et al. Fluid management in patients undergoing cardiac surgery: effects of an acetate- versus lactate-buffered balanced infusion solution on hemodynamic stability (HEMACETAT). Crit Care 2019; 23: 159
• 10 Duffy RA, Foroozesh MB, Loflin RD. et al. Normal saline versus Normosol-R in sepsis resuscitation: A retrospective cohort study. J Intensive Care Soc 2019; 20: 223-230
• 11 Hammond NE, Bellomo R, Gallagher M. et al. The Plasma-Lyte 148v Saline (PLUS) study protocol: a multicentre, randomised controlled trial of the effect of intensive care fluid therapy on mortality. Crit Care Resusc 2017; 19: 239-246
• 12 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
• 13 Zhang Z, Zhu C, Mo L. et al. Effectiveness of sodium bicarbonate infusion on mortality in septic patients with metabolic acidosis. Intensive care medicine 2018; 44: 1888-1895
• 14 Chowdhury AH, Cox EF, Francis ST. et al. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 2012; 256: 18-24
• 15 Yunos NM, Bellomo R, Hegarty C. et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. Jama 2012; 308: 1566-1572
• 16 Semler MW, Wanderer JP, Ehrenfeld JM. et al. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am J Respir Crit Care Med 2017; 195: 1362-1372
• 17 Funke BE, Jackson KE, Self WH. et al. Effect of balanced crystalloids versus saline on urinary biomarkers of acute kidney injury in critically ill adults. BMC nephrology 2021; 22: 54
• 18 Brown RM, Wang L, Coston TD. et al. Balanced Crystalloids versus Saline in Sepsis. A Secondary Analysis of the SMART Clinical Trial. Am J Respir Crit Care Med 2019; 200: 1487-1495
• 19 Jackson KE, Wang L, Casey JD. et al. Effect of Early Balanced Crystalloids Before ICU Admission on Sepsis Outcomes. Chest 2021; 159: 585-595
• 20 Maheshwari K, Turan A, Makarova N. et al. Saline versus Lactated Ringer's Solution: The Saline or Lactated Ringer's (SOLAR) Trial. Anesthesiology 2020; 132: 614-624
• 21 Futier E, Garot M, Godet T. et al. Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial. Jama 2020; 323: 225-236
• 22 Kabon B, Sessler DI, Kurz A. et al. Effect of Intraoperative Goal-directed Balanced Crystalloid versus Colloid Administration on Major Postoperative Morbidity: A Randomized Trial. Anesthesiology 2019; 130: 728-744
• 23 Wiedermann CJ, Joannidis M. Accumulation of hydroxyethyl starch in human and animal tissues: a systematic review. Intensive care medicine 2014; 40: 160-170
• 24 Heringlake M, Berggreen AE, Reemts E. et al. Fluid Therapy With Gelatin May Have Deleterious Effects on Kidney Function: An Observational Trial. Journal of cardiothoracic and vascular anesthesia 2020; 34: 2674-2681
• 25 Caironi P, Tognoni G, Masson S. et al. Albumin replacement in patients with severe sepsis or septic shock. The New England journal of medicine 2014; 370: 1412-1421