Kernaussagen
Bei positiver Druckbeatmung mit PEEP werden Natrium und Wasser retiniert. Die Abnahme der renalen Wasser- und Natriumausscheidung bei PEEP-Beatmung hat viele Ursachen. Es handelt sich primär nicht um eine „Nierenfunktionsstörung”, sondern um eine physiologische Anpassungsreaktion, die zur Pathogenese des Nierenversagens beitragen kann.
Regelkreise
Bei Hypo- und Normovolämie scheinen der Anstieg des ADH und die Aktivierung des Renin-Angiotensin-Aldosteron-Systems die wesentlichen Faktoren für die Retention zu sein.
Der ADH-Anstieg unter PEEP-Beatmung wird durch eine Hypervolämie vermindert.
Bei Hypervolämie gehören der Anstieg des Nierenvenendrucks und die Aktivierung des Renin-Angiotensin-Systems zu den wesentlichen Faktoren für die Retention.
Die hämodynamischen Beatmungseffekte führen über intrathorakale Volumen- und Barorezeptoren zu einer verstärkten neuronalen Aktivität, die auch die Aktivität des renalen Sympathikus betrifft, welcher jedoch für die Natrium- und Wasserretention unter PEEP-Beatmung wahrscheinlich eine untergeordnete Rolle spielt.
Beatmung und Nierenversagen
Ein akutes Nierenversagen kann durch maschinelle Ventilation verursacht oder verschlimmert werden.
Für schädigende Effekte der maschinellen Ventilation sind Komorbiditäten des Herz-Kreislauf-Systems, der Lunge und des Stoffwechsels ausschlaggebend.
Die Entwicklung einer Nierenschädigung unter Beatmung ist ein multifaktorielles Geschehen.
Literatur
-
1
Levey A S, Bosch J P, Lewis J B, Greene T, Rogers N, Roth D.
A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group.
Ann Intern Med.
1999;
130
461-470
-
2
Levey A S, Coresh J, Balk E, Kausz A T, Levin A, Steffes M W, Hogg R J, Perrone R D, Lau J, Eknoyan G.
National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
Ann Intern Med.
2003;
139
137-147
-
3
Kuiper J W, Groeneveld A B, Slutsky A S, Plotz F B.
Mechanical ventilation and acute renal failure.
Crit Care Med.
2005;
33
1408-1415
-
4
Cockcroft D W, Gault M H.
Prediction of creatinine clearance from serum creatinine.
Nephron.
1976;
16
31-41
-
5
Gattinoni L, Caironi P, Carlesso E.
How to ventilate patients with acute lung injury and acute respiratory distress syndrome.
Curr Opin Crit Care.
2005;
11
69-76
-
6
Kreit J W, Eschenbacher W L.
The physiology of spontaneous and mechanical ventilation.
Clin Chest Med.
1988;
9
11-21
-
7
Biondi J W, Schulman D S, Matthay R A.
Effects of mechanical ventilation on right and left ventricular function.
Clin Chest Med.
1988;
9
55-71
-
8
Biondi J W, Schulman D S, Soufer R, Matthay R A, Hines R L, Kay H R, Barash P G.
The effect of incremental positive end-expiratory pressure on right ventricular hemodynamics and ejection fraction.
Anesth Analg.
1988;
67
144-151
-
9 Comroe J, Forster R, Dubois A, Briscoe W, Carlsen E. The Lung - Clinical Physiology and Pulmonary Function Tests. Chicago, London; Year Book Medical Publishers Inc 1962
-
10
Drury D R, Henry J P, Goodman J.
The Effects of Continuous Pressure Breathing on Kidney Function.
J Clin Invest.
1947;
26
945-951
-
11
Murdaugh jr H V, Sieker H O, Manfredi F.
Effect of altered intrathoracic pressure on renal hemodynamics, electrolyte excretion and water clearance.
J Clin Invest.
1959;
38
834-842
-
12
Steinhoff H H, Kohlhoff R J, Falke K J.
Facilitation of renal function by intermittent mandatory ventilation.
Intensive Care Med.
1984;
10
59-65
-
13
Hall S V, Johnson E E, Hedley-Whyte J.
Renal hemodynamics and function with continuous positive-pressure ventilation in dogs.
Anesthesiology.
1974;
41
452-461
-
14
Farge D, De la Coussaye J E, Beloucif S, Fratacci M D, Payen D M.
Interactions between hemodynamic and hormonal modifications during PEEP-induced antidiuresis and antinatriuresis.
Chest.
1995;
107
1095-1100
-
15
Annat G, Viale J P, Bui Xuan B. et al .
Effect of PEEP ventilation on renal function, plasma renin, aldosterone, neurophysins and urinary ADH, and prostaglandins.
Anesthesiology.
1983;
58
136-141
-
16 Rossaint R. Auswirkungen der maschinellen Beatmung mit positiv end-exspiratorischem Druck auf den Natrium-Wasser-Haushalt - Eine Untersuchung an wachen Hunden. Habilitationsschrift: Klinik für Anästhesiologie und operative Intensivmedizin. Berlin; Universitätsklinikum Rudolf Virchow der Freien Universität Berlin 1992: 129 S
-
17
Rossaint R, Jorres D, Nienhaus M, Oduah K, Falke K, Kaczmarczyk G.
Positive end-expiratory pressure reduces renal excretion without hormonal activation after volume expansion in dogs.
Anesthesiology.
1992;
77
700-708
-
18
Schrier R W.
Pathogenesis of sodium and water retention in high-output and low-output cardiac failure, nephrotic syndrome, cirrhosis, and pregnancy (1).
N Engl J Med.
1988;
319
1065-1072
-
19
Venus B, Mathru M, Smith R A, Pham C G, Shirakawa Y, Sugiura A.
Renal function during application of positive end-expiratory pressure in swine: effects of hydration.
Anesthesiology.
1985;
62
765-769
-
20
Qvist J, Pontoppidan H, Wilson R S, Lowenstein E, Laver M B.
Hemodynamic responses to mechanical ventilation with PEEP: the effect of hypervolemia.
Anesthesiology.
1975;
42
45-55
-
21
Navar L G.
Regulation of renal hemodynamics.
Adv Physiol Educ.
1998;
275
221-235
-
22
Reinhardt H W, Eisele R, Kaczmarczyk G, Mohnhaupt R, Oelkers W, Schimmrich B.
The control of sodium excretion by reflexes from the low pressure system independent of adrenal activity. Experiments on conscious dogs.
Pflugers Arch.
1980;
384
171-176
-
23
Berry A J, Geer R T, Marshall C, Wu W H, Zbuzek V M, Marshall B E.
The effect of long-term controlled mechanical ventilation with positive end-expiratory pressure on renal function in dogs.
Anesthesiology.
1984;
61
406-415
-
24
Priebe H J, Heimann J C, Hedley-Whyte J.
Mechanisms of renal dysfunction during positive end-expiratory pressure ventilation.
J Appl Physiol.
1981;
50
643-649
-
25
Schrier R W, Humphreys M H.
Factors involved in antinatriuretic effects of acute constriction of the thoracic and abdominal inferior vena cava.
Circ Res.
1971;
29
479-489
-
26
Rossaint R, Krebs M, Forther J, Unger V, Falke K, Kaczmarczyk G.
Inferior vena caval pressure increase contributes to sodium and water retention during PEEP in awake dogs.
J Appl Physiol.
1993;
75
2484-2492
-
27
Abildgaard U, Amtorp O, Holstein-Rathlou N H, Agerskov K, Sjontoft E, Christensen N J, Leyssac P P.
Effect of renal venous pressure elevation on tubular sodium and water reabsorption in the dog kidney.
Acta Physiol Scand.
1988;
132
135-142
-
28
Kaczmarczyk G, Rossaint R, Altmann C, Falke K, Mohnhaupt R, Reinhardt H W.
ACE inhibition facilitates sodium and water excretion during PEEP in conscious volume-expanded dogs.
J Appl Physiol.
1992;
73
962-967
-
29
Boemke W, Krebs M O, Djalali K, Bunger H, Kaczmarczyk G.
Renal nerves are not involved in sodium and water retention during mechanical ventilation in awake dogs.
Anesthesiology.
1998;
89
942-953
-
30
Steinhoff H H, Samodelov L F, Trampisch H J, Falke K J.
Cardiac afferents and the renal response to positive pressure ventilation in the dog.
Intensive Care Med.
1986;
12
147-152
-
31
Kaczmarczyk G, Vogel S, Krebs M, Bunger H, Scholz A.
Vasopressin and renin-angiotensin maintain arterial pressure during PEEP in nonexpanded, conscious dogs.
Am J Physiol.
1996;
271
R1396-402
-
32
Kaczmarczyk G, Jorres D, Rossaint R, Krebs M, Unger V, Falke K.
Extracellular volume expansion inhibits antidiuretic hormone increase during positive end-expiratory pressure in conscious dogs.
Clin Sci (Lond).
1993;
85
643-649
-
33
Andrivet P, Adnot S, Sanker S, Chabrier P E, Macquin-Mavier I, Braquet P, Brun-Buisson C.
Hormonal interactions and renal function during mechanical ventilation and ANF infusion in humans.
J Appl Physiol.
1991;
70
287-292
-
34
Payen D M, Farge D, Beloucif S, Leviel F, De La Coussaye J E, Carli P, Wirquin V.
No involvement of antidiuretic hormone in acute antidiuresis during PEEP ventilation in humans.
Anesthesiology.
1987;
66
17-23
-
35
Krebs M O, Kröhn T, Boemke W, Mohnhaupt R, Kaczmarczyk G.
Renal and hemodynamic effects of losartan in conscious dogs during controlled mechanical ventilation.
Am J Physiol.
1999;
276
F425-432
-
36
Wenz M, Eckelt N, Rissel F, Kaczmarczyk G.
Short-term ACE inhibition has no effect on sodium and water excretion during PEEP ventilation.
Eur J Anaesthesiol.
1997;
14
566-575
-
37
Francis R C, Höhne C, Kaczmarczyk G, Boemke W.
Effect of angiotensin II and endothelin-1 receptor blockade on the haemodynamic and hormonal changes after acute blood loss and after retransfusion in conscious dogs.
Acta Physiol Scand.
2004;
180
319-328
-
38
Kharasch E D, Yeo K T, Kenny M A, Buffington C W.
Atrial natriuretic factor may mediate the renal effects of PEEP ventilation.
Anesthesiology.
1988;
69
862-869
-
39
Ramamoorthy C, Rooney M W, Dries D J, Mathru M.
Aggressive hydration during continuous positive-pressure ventilation restores atrial transmural pressure, plasma atrial natriuretic peptide concentrations, and renal function.
Crit Care Med.
1992;
20
1014-1019
-
40
Andrivet P, Adnot S, Brun-Buisson C, Chabrier P E, Darmon J Y, Braquet P, Lemaire F.
Involvement of ANF in the acute antidiuresis during PEEP ventilation.
J Appl Physiol.
1988;
65
1967-1974
-
41
Kaczmarczyk G, Christe W, Mohnhaupt R, Reinhardt H W.
An attempt to quantitate the contribution of antidiuretic hormone to the diuresis of left atrial distension in conscious dogs.
Pflugers Arch.
1983;
396
101-105
-
42
Thames M D.
Contribution of cardiopulmonary baroreceptors to the control of the kidney.
Fed Proc.
1978;
37
1209-1213
-
43
Fewell J E, Bond G C.
Renal denervation eliminates the renal response to continuous positive-pressure ventilation.
Proc Soc Exp Biol Med.
1979;
161
574-578
-
44
Fewell J E, Bond G C.
Role of sinoaortic baroreceptors in initiating the renal response to continuous positive-pressure ventilation in the dog.
Anesthesiology.
1980;
52
408-413
-
45
DiBona G F.
Neurogenic regulation of renal tubular sodium reabsorption.
Am J Physiol.
1977;
233
F73-81
-
46
Jacob F, Ariza P, Osborn J W.
Renal denervation chronically lowers arterial pressure independent of dietary sodium intake in normal rats.
Am J Physiol Heart Circ Physiol.
2003;
284
H2302-2310
-
47
DiBona G F, Kopp U C.
Neural control of renal function.
Physiol Rev.
1997;
77
75-197
-
48
Kaczmarczyk G, Mohnhaupt R, Reinhardt H W.
Renal sodium handling in intact and renal denervated dogs.
Pflugers Arch.
1986;
407
382-387
-
49
Jacob L P, Chazalet J J, Payen D M, Villiers S M, Boudaoud S, Teillac P, Pruna A S, Idatte J M, Eurin B G.
Renal hemodynamic and functional effect of PEEP ventilation in human renal transplantations.
Am J Respir Crit Care Med.
1995;
152
103-107
-
50
Vivino G, Antonelli M, Moro M L, Cottini F, Conti G, Bufi M, Cannata F, Gasparetto A.
Risk factors for acute renal failure in trauma patients.
Intensive Care Med.
1998;
24
808-814
-
51
Wiedemann H P, Wheeler A P, Bernard G R, Thompson B T, Hayden D, deBoisblanc B, Connors jr A F, Hite R D, Harabin A L.
Comparison of two fluid-management strategies in acute lung injury.
N Engl J Med.
2006;
354
2564-2575
Dr. Roland C. E. Francis
Klinik für Anästhesiologie und operative Intensivmedizin, Charité - Universitätsmedizin Berlin
Campus Virchow-Klinikum
Augustenburger Platz 1
13353 Berlin
Telefon: 030/450-551022
Fax: 030/450-551900
eMail: roland.francis@charite.de
