Das akute Nierenversagen: Nierenversagen: Ursache für CNI/ DialysepflichtigDialysepflichtigkeit nach ICU Prof. Dr. Wilfred Druml Abteilung fü für Nephrologie und Dialyse Medizinische Universitä Universitätsklinik III Allgemeines Krankenhaus Wien Österreich

F-1818-11

KurzKurz- und Langezeitkomplikationen der Akuten Nierenschädigung (ANS) Wir waren naiv und haben geglaubt, dass…. 1. kleine Schwankungen der Nierenfunktion bzw. KreatininKreatininÄnderungen vernachlässigbar sind.. 2. das ANV eine „harmlose“ Komplikation darstellet, das die Nierenfunktion beliebig lange durch RRT ersetzt werden kann 3. Patienten „im“ ANV aber nicht „am“ ANV versterben 4. Bei Patienten, die eine ANS überleben, die Nierenfunktion sich vollständig erholt 5. Patienten, die ein ANV überleben, alles so ist wie vorher…

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Epidemiology of Acute Kidney Injury Cerda J et al.

Clin J Am Soc Nephrol. 2008; 3:881-6 Natural history of AKI. Patients who develop AKI may experience (1) complete recovery of renal function, (2) development of progressive chronic kidney disease (CKD), (3) exacerbation of the rate of progression of preexisting CKD; A-o-C (4) irreversible loss of kidney function and evolve into ESRD

DialysisDialysis-requiring acute renal failure increases the risk of progressive chronic kidney disease Lo LJ. et al.

Kidney int 2009; 76: 893-99.

Kaplan–Meier curves showing long-term risk of progressive chronic kidney disease (CKD) (stage 4 or higher) among patients who did (dashed line) or did not (solid line) suffer acute renal failure.

Epidemiology of renal recovery after acute renal failure Bagshaw SM et al . Curr Opin Crit Care 2006; 12:544-50

Summary of studies of critically ill patients reporting renal recovery to independence from renal replacement therapy at hospital discharge

Evolution of chronic renal impairment and longlong-term mortality after de novo acute kidney injury in the critically ill; ill; a Swedish multimulti-centre cohort study RimesRimes-Stigare C. et al.

Crit Care 2015; 19: 221

Estimates of survival, end-stage renal disease (ESRD) and chronic kidney disease (CKD) three years after ICU admission in patients with AKI and patients with no AKI. Kaplan-Meier curves for cumulative mortality (A), ESRD (B), and CKD (C).

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Long-term risk of chronic kidney disease and mortality in children after acute kidney injury: a systematic review Greenberg JH. et al.

BMC Nephrol 2014; 15: 184

Cumulative long-term rates of renal outcomes and mortality

Chronic kidney disease after acute kidney injury: injury: a systematic review and metameta-analysis Coca SG. et al. Kidney Int 2012; 81: 442442-48

LongLong-term risk of mortality and acute kidney injury during hospitalization after major surgery Bihorac A. et al.

Ann Surg 2009; 249: 851-59

Long-term survival of patients with and without an episode of AKI during hospitalization, stratified by degree of renal recovery.

Nonrecovery of kidney function and death after „acute on chronic“ chronic“ renal failure Hsu CY et al.

Clin J Am Soc Nephrol. 2009;4:891-8. Long-term ESRD-free survival (absence of death or ESRD) among patients who had CKD and who did not develop ESRD or death within 30 d of discharge from index hospitalization. Dashed line represents those who experienced superimposed ARF (n = 213); Solid line represents those who did not (n = 34,721).

Meta-analysis of chronic kidney disease (CKD) and end-stage renal disease (ESRD) associated with AKI. (a)Pooled adjusted hazard ratios (HRs) for CKD after AKI. (b)(b) Pooled adjusted HRs for ESRD after AKI

Nonrecovery of kidney function and death after acute on chronic renal failure Hsu CY et al.

Clin J Am Soc Nephrol. 2009;4:891-8.

Outcomes during and immediately after hospitalization for patients who had CKD and did or did not experience an episode of superimposed ARF, stratified by level of preadmission eGFR

LongLong-term mortality and risk factors for development of endend-stage renal disease in critically ill patients with and without chronic kidney disease Rimes-Cigare C. et al.

Crit Care 2015; 19:383-387

Kaplan-Meier curves showing a 5-year survival and b 3-year risk of developing ESRD according to renal disease status.

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Altersverteilung von Patienten mit Akutem Nierenversagen auf der ICU

Mittleres Alter fast 70 Jahre!!

AKUTES NIERENVERSAGEN

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Risikofaktoren „chronisch“ „susceptibility factors“ Nicht modifizierbar Vorbestehende Niereninsuffizienz fortgeschrittenes Alter Hypertonie Diabetes mellitus I / II Herzinsuffizienz Leberinsuffizienz Nephrotisches Syndrom .....

Komorbiditäten

aus der ASDI-Datenbank – Österreichische Intensivstationen im Jahr 2014

Beachte : Das ANV trifft selten „Nieren-naive“ Patienten !

Acute kidney injury increases risk of ESRD among elderly

LongLong-Term Sequelae of Severe Acute Kidney Injury in the Critically Ill Patient without Comorbidity: Comorbidity: A Retrospective Cohort Study

Ishani A. et al.

JASN 2009; 20:223-28

Fortrie G. et al.

Likelihood of initiating ESRD treatment after acute kidney injury (AKI).

Renal recovery after severe acute renal failure Bagshaw, Bagshaw, SM et al.

Int J Art Organ 2006; 29:102329:1023-31

PLoS One 2015; 892–900

Kaplan-Meier curves for overall survival after hospital discharge stratified by comorbidity

Acute kidney injury and chronic kidney disease as interconnected syndromes Chawla LS. et al. N Engl J Med 2014; 371: 5858-66

Multivariate logistic regression model of factors independently associated with RENAL RECOVERY at 90 days among critically ill patients with severe ACUTE RENAL FAILURE

Pathophysiological Features of Acute Kidney Injury Leading to Chronic Kidney Disease

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Hypoxia as a key player in the AKIAKI-toto-CKD transition

Renale Inflammation macht interstitielle Fribrose The role of macrophages in renal fibrosis Meng XM. et al. Nat Rev Nephrol 2010; 14: 493493-503

Tanaka S. et al. Am J Physiol 2014; 307:F1187307:F1187-95

Renal hypoxia in the pathophysiology of the acute kidney injury (AKI)-to-chronic kidney disease (CKD) transition.

Nierenfunktion nach akuter Nierenschädigung

Renal injury can lead to the accumulation of classicallyactivated M1 proinflammatory macrophages in the kidney.

Elevated BP after AKI Hsu CY. et al.

J Am Soc Nephrol 2015; e-pub

BEACHTE: Cumulative incidence of elevated BP (systolic BP>140 mmHg and/or diastolic BP>90 mmHg) during the first 2 years after discharge among patients with and without AKI.

Eine Normalisierung des Serum-Kreatinin bedeutet nicht eine komplette Erholung der Nierenfunktion…

We conclude that AKI is an independent risk factor for subsequent development of elevated BP.

LongLong-term risk of coronary events after AKI Wu VC. et al.

J Am Soc Nephrol 2014; 25: 595-605

The Impact of Acute Kidney Injury on the LongLong-term Risk of Stroke Wu VC. et al.

Am J Heart Assoc 2014; 3: e0000933

Kaplan–Meier curves of being free from stroke in the AKI-recovery and non-AKI groups (P=0.0025). AKI indicates acute kidney injury (A) Adjusted HRs for long-term risk of coronary events stratified by status of DM and AKI *P