Behandlung der Nierenarterienstenose im Jahr 2021

Treatment of renal artery stenosis in the year 2021

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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Literatur

  1. 1.

    Hunt JC, Strong CG (1973) Mayo Clinic: renovascular hypertension. Mechanisms, natural history and treatment. Am J Cardiol 32:562–574

    CAS  PubMed  Google Scholar 

  2. 2.

    Pickering TG, Mann SJ (1995) Renovascular hypertension: medical evaluation and nonsurgical treatment. In: Laragh JH, Brenner BM (Hrsg) Hypertension: pathophysiology, diagnosis and management. Raven Press, New York, S 2039–2054

    Google Scholar 

  3. 3.

    de Mast Q, Beutler JL (2009) The prevalence of atherosclerotic renal artery stenosis in risk groups: a systematic literature review. J Hypertens 27:1333–1340

    PubMed  Google Scholar 

  4. 4.

    Vassallo D, Ritchie J, Green D et al (2018) The effect of revascularization in patients with anatomically significant atherosclerotic renovascular disease presenting with high-risk clinical features. Nephrol Dial Transplant 33:497–506

    CAS  PubMed  Google Scholar 

  5. 5.

    Garovic VD, Kane GC, Schwartz GL (2005) Renovascular hypertension: balancing the controversies in diagnosis and treatment. Cleve Clin J Med 72:1135–1147

    PubMed  Google Scholar 

  6. 6.

    Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C et al (2009) Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 361:1953–1962. https://doi.org/10.1056/NEJMoa0905368

    Article  PubMed  Google Scholar 

  7. 7.

    Cooper CJ, Murphy TP, Cutlip DE et al (2014) Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 370:13–22

    CAS  PubMed  Google Scholar 

  8. 8.

    Bax L, Woittiez AJ, Kouwenberg HJ, Mali WP, Buskens E, Beek FJ, Braam B, Huysmans FT, Schultze Kool LJ, Rutten MJ, Doorenbos CJ, Aarts JC, Rabelink TJ, Plouin PF, Raynaud A, van Montfrans GA, Reekers JA, van den Meiracker AH, Pattynama PM, van de Ven PJ (2009) Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med 150:840–848

    PubMed  Google Scholar 

  9. 9.

    Safian RD, Textor SC (2001) Renal artery stenosis. N Engl J Med 344:431–442

    CAS  PubMed  Google Scholar 

  10. 10.

    Messerli FH, Bangalore S, Makani H et al (2011) Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome. Eur Heart J 32:2231–2235. https://doi.org/10.1093/EURHEARTJ/EHR056

    Article  PubMed  Google Scholar 

  11. 11.

    Conlon PJ, Little MA, Pieper K et al (2001) Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int 60:1490–1407

    CAS  PubMed  Google Scholar 

  12. 12.

    Johansson M, Herlitz H, Jensen G, Rundqvist B, Friberg P (1999) Increased cardiovascular mortality in hypertensive patients with renal artery stenosis. Relation to sympathetic activation, renal function and treatment regimens. Hypertension 17:1743–1750

    CAS  Google Scholar 

  13. 13.

    Colyer WR, Cooper CJ (2011) Management of renal artery stenosis 2010. Curr Treat Options Cardiovasc Med 13:103–113

    PubMed  Google Scholar 

  14. 14.

    Novick AC (1995) Surgical revascularization for renovascular hypertension and preservation of renal function. In: Laragh JH, Brenner BM (Hrsg) Hypertension: pathophysiology, diagnosis and management, 2. Aufl. Raven Press, New York, S 2055–2068

    Google Scholar 

  15. 15.

    Grüntzig A, Kuhlmann U, Vetter W et al (1978) Treatment of renovascular hypertension with percutaneous transluminal dilatation of a renal-artery stenosis. Lancet 8068:801–802

    Google Scholar 

  16. 16.

    Dorros G, Jaff M, Mathiak L, Dorros II, Lowe A, Murphy K, He T (1998) Four-year follow-up of Palmaz-Schatz-stent revasularization as treatment for atherosclerotic renal artery stenosis. Circulation 98:642–647

    CAS  PubMed  Google Scholar 

  17. 17.

    van de Ven PJG, Kaatee R, Beutler JJ, Beek FJ, Woittiez AJ, Buskens E et al (1999) Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomized trial. Lancet 353:282–286

    PubMed  Google Scholar 

  18. 18.

    Leertouwer TC, Pattynama PM, van den Berg-Huysmans A et al (2001) Incidental renal artery stenosis in peripheral vascular disease: a case for treatment? Kidney Int 59:1480–1483

    CAS  PubMed  Google Scholar 

  19. 19.

    van Jaarsveld BC, Krijnen P, Pieterman H et al (2000) The effect of baloon angioplasty on hypertension in atherosclerotic renal artery stenosis. N Engl J Med 342:1007–1014

    PubMed  Google Scholar 

  20. 20.

    Plouin PF, Chatellier G, Darne B, Raynaud A (1998) Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai multicentrique medicaments vs angioplastie (EMMA) study group. Hypertension 31:823–829

    CAS  PubMed  Google Scholar 

  21. 21.

    Webster J, Marshall F, Abdalla M, Dominiczak A, Edwards R, Isles CG, Loose H, Main J, Padfield P, Russell IT, Walker B, Watson M, Wilkinson R (1998) Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle renal artery stenosis collaborative group. J Hum Hypertens 12:329–335

    CAS  PubMed  Google Scholar 

  22. 22.

    Nordmann AJ, Woo K, Parkes R, Logan AG (2003) Balloon angioplasty or medical therapy for hypertensive patients with atherosclerotic renal artery stenosis? A meta-analysis of randomized controlled trials. Am J Med 114:44–50

    PubMed  Google Scholar 

  23. 23.

    Bavry AA, Kapadia SR, Bhatt DL, Kumbhani DJ (2014) Renal artery revascularization: updated meta-analysis with the CORAL trial. JAMA Intern Med 174(11):1849–1851. https://doi.org/10.1001/JAMAINTERNMED.2014.4332

    Article  PubMed  Google Scholar 

  24. 24.

    Raman G, Adam GP, Halladay CW, Langberg VN, Azodo IA, Balk EM (2016) Comparative effectiveness of management strategies for renalartery stenosis: an updated systematic review. Ann Intern Med 165:635–649

    PubMed  Google Scholar 

  25. 25.

    Ritchie J, Green D, Chrysochou C et al (2014) High-risk clinical presentations in atherosclerotic renovascular disease: prognosis and response to renal artery revascularization. Am J Kidney Dis 63:186–197

    PubMed  Google Scholar 

  26. 26.

    Kalra PA, Chryschou C, Green D et al (2010) The benefit of renal artery stenting in patients with atheromatous renovascular disease and advanced chronic kidney disease. Catheter Cardiovasc Interv 75:1–10

    PubMed  Google Scholar 

  27. 27.

    Bloch MJ, Trost DW, Pickering TG, Sos TA, August P (1999) Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renal artery stent placement. Am J Hypertens 12:1–7

    CAS  PubMed  Google Scholar 

  28. 28.

    Bray BH, Olin JW, Childs MB et al (2002) Clinical benefit of renal angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med 7:275–279

    Google Scholar 

  29. 29.

    Gray BH, Olin JW, Childs MB, Sullivan TM, Bacharach JM (2002) Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med 7:275–279

    PubMed  Google Scholar 

  30. 30.

    Prince M, Tafur JD, White CJ (2019) When and how should we revascularize patients with atherosclerotic renal artery stenosis? JACC Cardiovasc Interv 12(6):505–517. https://doi.org/10.1016/j.jcin.2018.10.023

    Article  PubMed  Google Scholar 

  31. 31.

    Weinrauch LA, D’Elia JA (2004) Renal artery stenosis: “fortuitous diagnosis,” problematic therapy. J Am Coll Cardiol 43:1614–1615

    PubMed  Google Scholar 

  32. 32.

    Dworkin LD, Cooper CJ (2009) Clinical practice. Renal artery stenosis. N Engl J Med 361:1972–1978

    CAS  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Oberhuber A, Hupp T, Richter GM et al (2019) Leitlinie – S2K Erkrankungen der Nierenarterie 004-008 AWMF

    Google Scholar 

  34. 34.

    Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ, Galanski M, Koch KM, Haller H (2001) Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med 344:410–417

    CAS  PubMed  Google Scholar 

  35. 35.

    Barrett BJ (1994) Contrast nephrotoxicity. J Am Soc Nephrol 5:125–137

    CAS  PubMed  Google Scholar 

  36. 36.

    McLaughlin K, Jardine AG, Moss JG (2000) Renal artery stenosis. BMJ 320:1124–1127

    CAS  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Rimmer JM, Gennari FJ (1993) Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med 118:712–719

    CAS  PubMed  Google Scholar 

  38. 38.

    Weibull H, Bergqvist D, Bergentz SE, Jonsson K, Hulthén L, Manhem P (1993) Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vasc Surg 18:841–850

    CAS  PubMed  Google Scholar 

  39. 39.

    Galaria II, Surowiec SM, Rhodes JM, Illig KA, Shortell CK, Sternbach Y, Green RM, Davies MG (2005) Percutaneous and open renal revascularizations have equivalent long-term functional outcomes. Ann Vasc Surg 19:218–228

    PubMed  Google Scholar 

  40. 40.

    Modrall JG, Rosero EB, Smith ST, Arko FR 3rd, Valentine RJ, Clagett GP, Timaran CH (2008) Operative mortality for renal artery bypass in the United States: results from the national inpatient sample. J Vasc Surg 48:317–332

    PubMed  Google Scholar 

  41. 41.

    Hansen KJ, Cherr GS, Craven TE, Motew SJ, Travis JA, Wong JM, Levy PJ, Freedman BI, Ligush J Jr, Dean RH (2000) Management of ischemic nephropathy: dialysis-free survival after surgical repair. J Vasc Surg 32:472–481

    CAS  PubMed  Google Scholar 

  42. 42.

    Crowley JI, Santos RM, Peter RH et al (1998) Progression of renal artery stenosis in patients undergoing cardiac catheterization. Am Heart J 136:913–918

    CAS  PubMed  Google Scholar 

  43. 43.

    Slovut DP, Olin JW (2004) Fibromuscular dysplasia. N Engl J Med 350:1862–1871

    CAS  PubMed  Google Scholar 

  44. 44.

    Bittl JA (2014) Treatment of atherosclerotic renovascular disease. N Engl J Med 370:78–79

    CAS  PubMed  Google Scholar 

  45. 45.

    Cheung CM, Patel A, Shaheen CN et al (2007) The effect of statins on the progression of atherosclerotic renovascular disease. Nephron Clin Pract 107:c35–42

    CAS  PubMed  Google Scholar 

  46. 46.

    Silva VS, Martin LC, Franco RJS et al (2008) Pleiotropic effects of statins may improve outcomes in atherosclerotic renovascular disease. Am J Hypertens 21:1163–1168

    CAS  PubMed  Google Scholar 

  47. 47.

    Williams B, Mancia G, Spiering W et al (2018) ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 39:3021–3104

    PubMed  Google Scholar 

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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