Behandlung der Nierenarterienstenose im Jahr 2021

Treatment of renal artery stenosis in the year 2021

Der Internist volume 62, pages252–262(2021)Cite this article

Zusammenfassung

Eine hämodynamisch wirksame arteriosklerotisch bedingte Nierenarterienstenose mit einer Lumeneinengung von mindestens 60–70 % kann zu unterschiedlichen Erkrankungen führen: bei unilateraler Stenose zu einer renovaskulären Hypertonie, bei bilateraler Stenose (bzw. bei stenosierter Einzelniere) auch zu einer oft progredienten Niereninsuffizienz (ischämische Nephropathie) und/oder zum akuten Lungenödem („pulmonary flash edema“). Kausal oft angestrebte revaskularisierende Verfahren (Angioplastie mit und ohne Stentapplikation, seltener gefäßchirurgische Verfahren) erreichen eine Wiedereröffnungsrate von über 90 %. Allerdings bleiben bei den katheterbasierten Interventionen die erhofften funktionellen Auswirkungen im Hinblick auf eine verbesserte Blutdruckeinstellung oder Nierenfunktion sowie auf eine verringerte Gesamtsterblichkeit nach den Ergebnissen randomisierter Studien hinter den Erwartungen zurück. Entsprechend wird einer optimalen medikamentösen Therapie der Vorzug gegeben. Patienten mit kritischer Stenosierung und stärker ausgeprägten klinischen Komplikationen wie rezidivierendem Lungenödem oder progredientem Nierenversagen können von einer revaskularisierenden Maßnahme profitieren. Im Einzelfall kann es daher vertretbar und im Sinne einer Ultima Ratio auch medizinisch notwendig sein, ein solches Verfahren einzusetzen. Die sorgfältige Auswahl geeigneter Patienten ist für den klinischen Erfolg ausschlaggebend.

Abstract

Severe arteriosclerotic stenosis of the renal artery with at least 60–70% narrowing of the lumen can lead to various diseases: in the case of unilateral stenosis it can lead to renovascular hypertension, in the case of bilateral narrowing (or in a stenotic solitary kidney) also to an often progressive renal insufficiency (ischemic kidney disease) and/or to acute pulmonary edema (pulmonary flash edema). Renal artery stenosis may be treated by revascularization using either percutaneous (balloon angioplasty with or without stenting) or less commonly open surgical procedures, both with excellent primary patency rates of over 90%; however, randomized trials of catheter-based interventions have failed to demonstrate a longer term benefit with respect to blood pressure control and renal function as well as improved overall survival over optimal medicinal management alone. Due to improved clinical outcomes interventional revascularization is justified in cases with critical stenoses and clinical sequelae, such as pulmonary flash edema and progressive renal failure. Careful patient selection is essential to maximize a potential clinical benefit.

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  1. KfH-Nierenzentrum, Maxstraße 48, 67059, Ludwigshafen, Deutschland

    Prof. Dr. med. Tomas Lenz

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Correspondence to Prof. Dr. med. Tomas Lenz.

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Lenz, T. Behandlung der Nierenarterienstenose im Jahr 2021. Internist 62, 252–262 (2021). https://doi.org/10.1007/s00108-020-00935-5

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Schlüsselwörter

  • Bilaterale Nierenarterienstenose
  • Ischämische Nephropathie
  • Rezidivierendes Lungenödem
  • Ballonangioplastie
  • Stentangioplastie

Keywords

  • Renal artery obstruction/bilateral
  • Renal disease/ischemic
  • Lung edema/recurrent
  • Angioplasty, balloon
  • Angioplasty, stent