Kontinuierliche Nierenersatztherapie in der Behandlung des akuten Nierenversagens: Geschichte und Entwicklung

Acute renal failure (ARF) is a frequent complication in patients with multiple organ failure and sepsis leading to a significant increase of mortality in these critically ill patients (50– 70%). While for years, ARF was considered an unavoidable complication of multiple organ failure and thus not essential for the progress, various studies in recent years have shown an independent and fundamental influence of ARF and therefore its therapy on the survival of the patient. In the late 1970s continuous forms of treatment were introduced into the intensive care units. The first form of this treatment option was continuous arteriovenous hemofiltration (CAVH), primarily developed for the treatment of overhydrated patients resistant to diuretics. Using pump driven forms of the treatment, such as venovenous hemofiltration or venovenous dialysis (CVVHD), nearly all patients can be treated sufficiently. CAVH in the early 1980s rarely exceeded a daily hemofiltrate of 8–15 L, while more recent randomized studies have shown that CVVH should be performed with an exchange amount of at least 35 ml/kg/h, which corresponds to a daily exchange of 60–80 L. With the abandonment of arterial puncture and the use of specialized equipment including CVVH machines, allowing a distinct balance in these critically ill, the most important disadvantages of the formerly used CAVH are eliminated but have also led to a loss of simplicity of the method. Scientific work in the next decade should focus on (local) anticoagulation and determination of the optimal amounts of hemofiltrate for different diseases.